肩峰撞击征二型肩峰行关节镜下肩峰成形术与关节镜下单纯肩峰下清理术疗效比较

Clinical outcomes of arthroscopic acromioplasty versus arthroscopic subacromial debridement for curved acromion in subacromial impingement syndrome

目的分析评价关节镜下肩峰成形术与关节镜下单纯肩峰下清理术在治疗肩峰撞击征二型肩峰患者的疗效比较。方法选取2013年6月至2014年12月大连医科大学附属第二医院收治的57例肩峰撞击征二型肩峰患者,随机分成2组,其中行关节镜下肩峰成形术组32例,男20例,女12例,平均年龄(51.53±8.87)岁(39~68岁);行关节镜下单纯肩峰下清理术组25例,男13例,女12例,平均年龄(53.52±8.53)岁(42~70岁)。术前、术后定期使用美国加州大学洛杉矶分校(University of California at Los Angeles,UCLA)肩关节评分对肩关节功能随访评测。结果所有患者均获得随访,随访平均时间(7.95±3.65)个月(3~18个月)。关节镜下肩峰成形术组术前UCLA评分(9.43±1.34)分,末次随访评分(33.15±3.78)分,优良率88%;关节镜下单纯肩峰下清理术组术前UCLA评分(6.40±1.15)分,末次随访评分(32.68±3.95)分,优良率84%。两组末次测评的UCLA评分较术前均明显提高,两组术后UCLA评分及优良率比较差异无统计学意义(χ2=0.009,P>0.05)。结论关节镜下肩峰成形术与关节镜下单纯肩峰下清理术都能明显改善肩峰撞击征二型肩峰患者的症状。肩峰撞击征二型肩峰患者更推荐行关节镜下单纯肩峰下清理术。

Background Subacromial impingement syndrome is one of the main cause of shoulder pain.When the satisfactory effect is not achieved with at least 3 months of conservative treatments including diathermy,hot compress and subacromial injection of the narcotic drugs,surgery becomes a reliable option for relieving the symptoms.Nowadays,arthroscopic acromioplasty and arthroscopic subacromial debridement are the two most commonly used surgical approaches in treating the subacromial impingement syndrome.The purpose of this study is to discuss the efficiency comparison between arthroscopic acromioplasty and arthroscopic subacromial debridement and their applicational values in better treating the type II acromion with subacromial impingement syndrome.Methods （1）General data.From June 2013 to December 2014,57 patients have been diagnosed with the type II acromion with subacromial impingement syndrome using the radiography in the second hospital of Dalian medical university.Through prospective randomized controlled method,patients were randomly assigned into 2 groups： 32 patients （20 male and 12 female） in the arthroscopic acromioplasty group with a mean age of （51.53±8.87） years （39 to 68 years）;25 patients （13 male and 12 female） in the arthroscopic subacromial debridement group with a mean age of （53.52±8.53） years （42 to 70 years）.Before the surgery was considered,all patients were suffered from shoulder pain and limited scope of active activities.The following specialized examinations were done： Neer sign（＋）,Hawkins sign（＋）,Job test（-）,painful arc：60-120°.The X-ray of the exit position of supraspinatus muscle suggested the type II acromion.All patients who followed the protocol of conservative treatment with a mean time of （7.95±3.65） months （3 to 18 months） did not meet their satisfaction.The patients with rotator cuff fractures suggested by MRI and other structural disorders of the shoulder including glenohumeral instability,frozen shoulder,Bankart damage and acromioclavicular arthritis were excluded from this study.（2）Operation method.The patient was kept with lateral position,and the trunk leaned back to 30 degrees with the shoulder abduction of 45 degrees.The forerake was 15 degrees,and the traction weight was about 3 kg.The glenohumeral joint was accessed from the standard posterior approach to explore glenohumeral labrum,subscapularis muscle,joint capsule ligament and long head of biceps tendon complex.Presences of the fracture on the bottom surface of the upper rotator cuff and the inflammation and wearing at the tendon sheath of the long head of biceps brachii muscle were further examined.①The arthroscopic subacromial debridement.After the glenohumeral joint examination,the subacromial space was accessed from the same posterior approach.The slippery bursa tissue was removed through the anterolateral approach in order to exposed the rotator cuff tendon.The healthy rotator cuff tendon is white,shiny,and the tendon fibers neatly arrange in parallel.However,the rotator cuff that undergoes pathological changes is gray,dark and disordered.While small torn existed in the rotator cuff tendon of individual patients,strengthen by suture was not required as the thickness of the tendon was enough to maintain the normal function of the rotator cuff.It is necessary to use the plane cutter to clean up the denatured shoulder sleeve tendon tissue along the shoulder sleeve fiber because the degenerate tissue is one of the main factors that cause the symptoms.②The arthroscopic acromioplasty.On the basis of simple cleaning,the arthroscopy lens accessed in to observe from the posterior approach.Then,the end of coracoacromial ligament of the anterolateral acromial was dissociated from the lateral approach to exposed the subacromial surface.Similar to the description of the type II acromion,it was found that the anterolateral margin of the acromion was slightly curved.The hyperplasia bone spur was even probed at the end of the curved acromion for some patients.The 3.5 mm grinding head was applied to flatten the curved anterolateral margin of the acromion.In order to ensure that the surface of the acromion is flat,the lens and the grinding head exchange approaches by having the anterolateral approach for observation and the posterior approach for supplemental polishing by the;grinding head.（3）Postoperative management.Rehabilitation exercise was performed starting from the second day after operation.From 1 week to 6 weeks,the passive activity was executed to avoid the joint adhesion.During the same period,the passive range of motion of the shoulder was also under recovery through practices.From 7 weeks to 12 weeks,the strengths of the rotator cuff muscle and the deltoid muscle were recovered via active exercise.From 4 months to 6 months,the low antagonistic movement or the low frequency movement of arm lifting over the shoulder was encouraged to participate appropriately.From 6 months to 12 months,the high-intensity combat sports or the high frequency movement of arm lifting over the shoulder was recommended to be tried.（4）Follow-up and curative effect evaluation.After the operation,the patients were followed up at the time point of 1 week,6 weeks,12 weeks.The contents of the follow-up included： functional exercises,active and passive activities of the affected limb,and the muscle strength of the affected limb.The University of California at Los Angeles （UCLA） shoulder score was regularly used to evaluate the shoulder joint function of the two groups of patients preoperatively and postoperatively.The pain and the functional evaluation include a score range of 10 points： 0 point for the worst and 10 points for the best;The activity,the muscle strength and the satisfactory evaluation include a score range of 5 points： 0 points for the worst and 5 points for the best;The UCLA evaluation has a full score of 35 points：34-35 for excellence;28-33 for good;21-27 for acceptable;0-20 for poor.Results Two groups of patients with a total number of 57 cases were all followed-up,and the second operation caused by the worsening of the symptoms was never required.Furthermore,other disease that affects the shoulder symptoms did not occur.The symptom,the function and the UCLA evaluation of the majority of patients have obvious improvements after the surgery.The arthroscopic acromioplasty group gets the preoperative UCLA score of （9.43±1.34） points,and the arthroscopic subacromial debridement group get the preoperative UCLA score of （9.64±1.41） points.There is no significant statistical difference between the joint function of the two groups of patients （P〉0.05）.After 1 week,the arthroscopic acromioplasty group gets the UCLA score of （14.19±1.73） points.During the same period,the arthroscopic subacromial debridement group get the UCLA score of （14.60±1.44） points.There is no significant improvement of the shoulder joint function for both groups 1 week after the operation （P〉0.05）,and there is no significant statistical difference between the two groups （P〉0.05）.After 6 weeks,the arthroscopic acromioplasty group gets the UCLA score of （20.56±2.69） points.At the same time,the arthroscopic subacromial debridement group get the UCLA score of （22.16±2.46） points.There is significant improvement of the shoulder joint function for both groups 6 weeks after the surgery （P〉0.05）,and there is no significant statistical difference between the two groups （P〉0.05）.After 12 weeks,the arthroscopic acromioplasty group gets the UCLA score of （26.47±3.26） points.At the same time,the arthroscopic subacromial debridement group get the UCLA score of （27.00±3.41） points.There is significant improvement of the shoulder joint function for both groups 12 weeks after the operation （P〉0.05）,and there is no significant statistical difference between the two groups （P〉0.05）.During the last follow-up,the arthroscopic acromioplasty group gets the UCLA score of （33.15±3.78） points.Meanwhile,the arthroscopic subacromial debridement group get the UCLA score of （32.68±3.95） points.There is no significant statistical difference between the recovery of the shoulder joint function of the two groups （P〉0.05）.After （11.34±2.03） months （8-15 months） of follow-up,the UCLA score of the arthroscopic acromioplasty group increases from （9.43±1.34） points to （33.15±3.78） points.After （11.20±1.89） months of follow-up,the UCLA score of the arthroscopic subacromial debridement group increases from （9.64±1.41） points to （32.68±3.95） points.The percentages of good and excellent are found to be 88% for the arthroscopic acromioplasty group and 84% for the arthroscopic subacromial debridement group.Conclusions While both surgical methods can significantly relieve the symptoms of patients with type II acromion,the arthroscopic subacromial debridement has advantages in treating the curved acromion.