改良切开修复巨大肩袖撕裂初步疗效分析

Analysis of early therapeutic effect of modified open repair of massive rotator cuff tear

目的评价改良切开修复巨大肩袖撕裂的临床疗效。方法回顾性分析自2012年3月至2015年3月东莞东华医院收治的行改良切开修复巨大肩袖撕裂患者10例的病例资料,其中男6例,女4例;年龄47~65岁,平均56.6岁;肩袖撕裂左7例,右3例。采用视觉模拟评分法(visual analysis scale,VAS)、Constant评分、美国加州大学洛杉矶分校(University of California at Los Angeles,UCLA)肩关节功能评分评价早期临床疗效。结果所有患者均获随访,随访时间为6~24个月,平均16.5个月。无切口感染、神经损伤。1例肩袖再撕裂,因患者疼痛轻、耐受好,未行翻修手术。VAS、UCLA、Constant评分均有改善,UCLA评分优3例,良5例,差2例,优良率为80%;Constant评分优3例,良5例,差2例,优良率为80%。结论采用改良切开修复巨大肩袖撕裂损伤较小,术后康复快,早期效果良好。

Background The rotator cuff is composed of supraspinatus,infraspinatus,subscapularis and teres minor,forming a sleeve structure around the anatomical neck of humerus.Due to the large bearing stress,the rotator cuff is easy to degenerate and its tear is common in clinical practice.Gerber,etc.defines massive rotator cuff tear as complete rupture of at least 2 tendons,which is widely accepted.The treatment of massive rotator cuff tear is difficult with poor outcomes.Although the shoulder arthroscopic technology has been mature,it is not popularized in the extensive primary hospitals,especially for the greater difficulty of arthroscopic repair.Methods （1） General information： From March 2012 to March 2015,10 patients of massive rotator cuff tear were treated with modified open repair in our hospital,including 6 males and 4 females,aged from 47 to 65 years with an average of 56.6 years;7 cases were in the left and 3 cases were in the right.（2）Operative methods： Under successful general anesthesia with endotracheal intubation,the patient was placed in beach chair position and the tracheal tube was properly fixed to avoid accidental slipping out.The bone landmarks such as acromion,coracoid process,etc.were marked after conventional disinfection and draping.As for patients combined with subscapularis injury,the subscapularis tendon was exposed after the ligation of the deltoid branch of thoracoacromial artery through the deltopectoral approach,and the partial or complete laceration was usually seen at the attachment point of small tuberosity with subluxation or dislocation of the long head of biceps tendon.One patient in this group was found to have Bankart injury and treated with a 3.5 mm suture anchor placed in the glenoid avulsion fracture to repair the joint capsule.After the reduction of the long head of biceps tendon,a 5.0 mm suture anchor was placed in lesser tuberosity with one suture penetrated through the end of subscapularis tendon and the other through transverse ligament.After the sutures were fastened with knots at the neutral position of shoulder joint,both the subscapularis tendon and the transverse tendon were repaired.One patient with shoulder joint dislocation had emergency manipulative reduction and received good recovery of Bankart lesion 2 months later.Without subscapularis injury,the following procedures were carried out directly.Through the small incision of anterolateral acromion and along the anterior and middle bundles of deltoid,the supraspinatus tendon was exposed to find the laceration and its retracted end and decide the tearing configuration.The shoulder joint was examined at 0° of shoulder abduction and the surgical release was unnecessary as the tension after repair was not large.Two 3.5 mm anchors were inserted into the greater tuberosity with sutures penetrated through the tearing rim of supraspinatus tendon.The knots were fastened at 0° of shoulder abduction and the repair was examined to be firm.The incision was closed as no malposition of anchors was found under fluoroscopy.（3）Postoperative management： The affected arm was in a sling for limitation of activities and wrist activities were encouraged immediately after anesthesia.The emphasis within 3 days was focused on pain control and the 2nd generation of cephalosporin was given regularly for postoperative infection prevention.The passive activities of forward flexion,abduction and external rotation were allowed 3 days later to distract the joint capsule and prevent adhesion,but not for the patient with subscapular injury.The active movements were also forbidden.The range of motion reached gradually at 90° of forward flexion,60° of abduction and 30° external rotation within 6 weeks （excluding patients with subscapular injury）.The active forward flexion,abduction and internal and external rotation was allowed 6 weeks later,and accompanied by climbing action and pulling rubber band,the active and passive exercises were permitted to carry out in patients with subscapularis injuries.The goal was to reach the normal range of shoulder motion at 3 months after the operation.3 months after operation,the strength training,such as raising barbell,pulling rubber band,etc.were carried out with long-term maintenance to consolidate the curative effect and prevention the function from decreasing again.Ice compress in the rehabilitation facilitated pain relief and the principle of gradual improvement should be followed to avoid the palindromia rotator cuff tear.（4）Assessment of curative effect： The curative effect assessment of shoulder joint was completed by one clinician independently with visual analysis scale （VAS）,Constant-Murley score and University of California at Los Angeles （UCLA） score.The total score of VAS was 10 points with 0 point for pain free,less than 3 points for slight and tolerable pain,4-6 points for mild pain which may affect the sleep but is still endurable and 7-10 points for severe and insufferable pain.The total score of Constant-Murley was 100 points with 90-100 points in excellent,80-89 points in good,70-79 points in normal and less than 70 points in poor.The total score of UCLA was 35 points with 34-35 points in excellent,29-33 points in good and less than 29 points in poor.Results All patients were followed up for 6 to 24 months with an average of 16.5 months.No incision infection or nerve injury was found.One patient had the recurrence of rotator cuff tear,but had no revision surgery due to the slight pain and his good tolerance.VAS score,UCLA score and Constant-Murley score were all improved.According to UCLA score and Constant-Murley score,there were 3 excellent cases,5 good cases and 2 poor cases,including 1 case of recurrence and 1 case of shoulder joint stiffness.The excellent and good rate was 80%.Conclusions Due to limited cases and experience,the remained problem is still complex,especially the basic study of shoulder biomechanics,biological repair of tendon tissue and pathology,and the treatment of long head injury of biceps tendon.The clinical effect requires long-term follow-ups and further analysis.In summery,the massive rotator cuff tear can be easily exposed and treated through modified open repair without stringing the anterior attachment of deltoid,which saves the operation time,accelerates the postoperative rehabilitation and particularly has the promotion value in hospitals and clinicians with insufficient shoulder arthroscopic experience.