关节镜下修复巨大肩袖损伤的临床研究

Clinical and MRI results of arthroscopic repair for massive rotator cuff tear

目的探讨关节镜下修复巨大肩袖损伤术后2年的临床效果。方法回顾性分析2010年10月至2013年3月，关节镜下治疗77例（79肩）巨大肩袖损伤患者资料，男42例（44肩），女35例（35肩）；年龄43．1-80．4岁，平均57．4岁；右64肩，左15肩；70例患肩为主力侧；52肩有外伤病史；术前症状持续时间〈3个月42肩，3-6个月11肩，6-12个月11肩，超过1年15肩；所有病例均为初次手术。术后行MR检查，测量肩关节活动度、前屈上举肌力、体侧外旋肌力，采用美国肩肘外科（American Shoulder ＆ Elbow Surgeons，ASES）评分评估肩关节功能，并与术前比较。结果77例患者随访时间均超过2年。末次随访时，所有的肩关节前屈上举活动度（156．9°±20．0°vs103．2°±54．5°）、体侧外旋活动度（40．6°±15．5°vs32．0°±21．4°）、内旋活动度（L2vsL1）、前屈上举肌力[（9．7±4．7）1bvs（4．6±4．9）lb]，体侧外旋肌力[（11．1±5．1）1bvs（8．3±5．4）1b]及ASES评分（82．7±14．6vs45．2±17．4）均较术前有显著性改善。在11个肩关节中，因撕裂肩袖肌腱明显退缩及受累肩袖肌肉严重萎缩，故术中只能修复部分肌腱；其余68肩完全修复。末次终随访时，部分修复的肩关节前屈上举活动度（146．4°±31．4°vs110．0°±56．70）、体侧外旋活动度（45．0°±14．8°vs34．1°±20．8°）及ASES评分（78．6±14．9vs54．5±13．9）仍较术前有显著性改善；完全修复的肩关节前屈上举肌力[（10．5±4．9）1bvs（6．2±3．2）1b]和体侧外旋肌力[（11．5±5．1）1bvs（8．3±3．8）1b]明显优于部分修复者。68肩完全修复的肩关节中，20肩术后1年MRI示修复肩袖肌腱再撕裂，再撕裂率29.4％（20／68）。术后肌腱再撕裂者均未接受再次手术治疗。术后20肩肌腱再撕裂患者的前屈上举活动度（152．0°±23．3°vs103．5°±60．5°）、前屈上举肌力[（8．5±4．7）1bvs（5．0±4．7）1b]以及ASES评分（76．9±16．5vs40．8±18．6）仍较术前有显著性改善。48肩修复肌腱完全愈合者的肩关节前屈上举活动度（161．4°±13．4°vs152．0°±23．3°）、前屈上举肌力[（11．3±4．7）1bvs（8．5±4．7）1b]、体侧外旋肌力[（12．4±4．8）1bvs9．6±5．3）1b]以及ASES评分（86．0±13．0VS76．9±16．5）明显优于修复肌腱再撕裂的患者。结论关节镜下肩袖修复术是治疗巨大肩袖损伤的有效方法，即使对术中肩袖肌腱仅部分修复或术后肩袖肌腱再撕裂者的肩关节功能仍较术前有显著改善。但术后肩袖肌腱完整愈合患者的肩关节功能优于部分修复或术后肌腱再撕裂者。

Objective To investigate the clinical and MRI outcomes of the arthroscopic rotator cuff repair for massive rotator cuff tear at minimum 2 years after surgery. Methods From October, 2010 to March, 2013, data of 79 shoulders in 77 patients with massive rotator cuff tear who were treated with arthroscopic rotator cuff repair were retrospectively analyzed. There were 42 male （44 shoulders） and 35 female （35 shoulders）. The average age before surgery was 57.4 years （43.1-80.4 years）. There were 64 right shoulders and 15 left shoulders. The dominate side were involved in 70 cases. A trauma history was documented in 52 shoulders. The symptoms persisted less than 3 months in 42 shoulders, between 3 and 6 months in 11 shoulders, between 6 and 12 months in 11 shoulders and more than 1 year in 15 shoulders. No revision case was included. The clinical results （range of motion, forward elevation strength, external rotation strength and American Shoulder ＆ Elbow Surgeons （ASES） score and MRI results were collected. Results All 77 cases were followed up more than 2 years. The forward elevation 056.9°±20.0° to 103.2°± 54.5°）, external rotation （40.6°±15.5° to 32.0°±21.4°）, internal rotation （L1 to L2）, forward elevation strength （9.7±4,7 lb to 4.6±4.9 lb）, external rotation strength （1 1.1 ±5.1 1b to 8.3±5.4 1b） and ASES score （82.7±14.6 to 45.2±17.4） were all improved significantly at the latest follow-up. During the surgery, complete repair were achieved in 68 shoulders. The forward elevation （146.4°±31.4° to 110.0°±56.7°）, external rotation （45.0°± 14.8° to 34.1°±20.8°） and ASES score （78.6±14.9 to 54.5±13.9） were all improved significantly at the latest follow-up in patients with partial repair during the surgery. But the forward elevation strength （10.5±4.9 1b to 6.2±3.21b） and external rotation strength （11.5±5.1 lb to 8.3±3.8 1b） were significantly better improved in patients who had complete repair. In 68 shoulders with complete repair during the surgery, 20 shoulders were found to have rotator cuff re-tear. The retear rate was 29.4%. But none of the patient with postoperative re-tear received revision surgery. The forward elevation （152.0± 23.3 to 103.5±60.5）, forward elevation strength （8.5±4.7 lb to 5.0±4.7 lb） and ASES score （76.9±16.5 to 40.8±18.6） were all ira-proved significantly at the latest follow-up in patients with postoperative re-tear of the rotator cuff tendon. But the forward elevation （161.4~±13.4~ to 152.0~±23.3~）, forward elevation strength （11.3±4.7 1b to 8.5±4.7 1b）, external rotation strength （12.4±4.8 lb to 9.6±5.3 lb） and ASES score （86.0±13.0 to 76.9±16.5） were significantly better in patients with complete healed rotator cuff tendon comparing with the re-tear group. Conclusion The rotator cuff repair can significantly improve the shoulder function of massive rotator cuff tear even when the rotator cuff tendon can only be partially repaired or re-tear after the surgery. The shoulder function is significantly better in patients with complete healed rotator cuff tendon comparing with the partial repair group and the re-tear group.