关节镜辅助下背阔肌腱转位联合肩袖修补治疗肩袖后上方不可修复的巨大撕裂

Arthroscopic lattisimus dorsi transfer with rotator cuff repair for posterosuperior irreparable massive rotator cuff tear

目的探讨关节镜辅助下背阔肌腱转位联合肩袖修补治疗不可修复的后上方肩袖巨大撕裂（irrepara—blemassive rotator cuff tear，iMRCT）的临床疗效。方法回顾性分析2014年9月至2015年12月，关节镜辅助下采用背阔肌腱转位联合肩袖修补治疗13例后上方iMRCT患者资料，男4例，女9例；年龄54-65岁，平均（58．5±4．3）岁；肩痛伴活动受限平均持续（2．1±0．6）年。术中先在关节镜下对后上方肩袖撕裂进行完全或部分修补，同时完全修复合并的肩胛下肌腱撕裂，切断或固定肱二头肌长头腱；然后于腋窝处作弧形切口，自肱骨止点处离断背阔肌腱，将肌腱编织后引入肩峰下间隙；再于关节镜下将背阔肌腱固定于肱骨大结节肩袖足印区。术前、术后第1天及末次随访时摄X线片及MRI，评价相关结构。检测体侧外旋、外展90°位外旋、前屈及外展主动活动度；采用视觉模拟评分（visual analog scale，VAS）评价疼痛；采用Constant—Murley和复旦大学肩关节评分（Fudan University shoulder score，FUSS）评估肩关节功能。结果13例患者均获得随访，随访时间17~22个月，平均（19．6±0．9）个月。无一例患者出现发热、感染、父节粘连、神经功能障碍等并发症，修复的肩袖未发现再撕裂。末次随访时X线片示平均肩峰肱骨距由术前（5．4±1．1）mm提升至（7．0±0．6）mm，MRI示修复肩袖及转位背阔肌腱固定牢固；患肩VAS评分由术前（4．8±1．3）分降至（0．5±0．7）分；体侧外旋、外展90°位外旋、前屈及外展主动活动度分别由术前的17．3°±10．5°、12．4°±7．8°、89．2°±41．2°、87．3°±40．7°提高至41．2°±12．5°、56．5°±16．6°、120．50±25．10、113．5°±25．4°；Constant—Murley评分由术前（33．5±9．9）分提升至（62．8±8．1）分；FUSS评分由术前（50．9±7．6）分改善至（81．7±7．0）分。术后所有指标分别与术前比较，差异均有统计学意义。结论关节镜辅助下背阔肌腱转位联合肩袖修补治疗后上方iMRCT疗效确切，可减轻患者疼痛，改善患者肩关节功能。

Objective To discuss the effect of arthroscopie latissimus dorsi transfer with rotator cuff repair for posterosuperior irreparable massive rotator cuff tear （iMRCT）. Methods From September 2014 to December 2015, data of 13 iMRCT including 4 male and 9 female who underwent arthroscopic latissimus dorsi transfer with rotator cuff repair were retrospectively analyzed. The age was ranged from 54 to 65, with a mean age of 58.5±4.3. The mean duration of symptom was 2.1±0.6 years. During operation, complete or partial rotator cuff repair was pertormed, tollowed by complete repair of injured subscapularis tendon and te- notomy or tenodesis of the long head of biceps tendon. An arc incision was then made in the axillary tossa to harvest latissimus dorsi tendon from its humeral insertion. The tendon was then introduced into subacromial space and fixed at the footprint of greater tuberosity arthroscopically. X-ray and MRI were conducted prior to and one day after the surgery and at the last follow-up. Pain visual analog scale （VAS） and active range of motion in all planes as well as Constant-Murley score and Fudan University shoulder score （FUSS） were documented betfore the surgery and at the last follow-up. Results All 13 patients accomplished the follow-up, with a duration from 17 to 22 months and a mean period of 19.6±0.9 months. No complications occurred. No re-tear was identified. The mean acromiohumeral distance increased from 5.4± 1.1 mm to 7.0±0.6 ram. The mean VAS decreased from 4.8± 1.3 to 0.5± 0.7. The mean 0° abduction external rotation, 90° abduction external rotation, flexion, as well as abduction increased fi＇om 17.3°± 10.5°, 12.4°±7.8°, 89.2°±41.2°, 87.3±40.7° to 41.2°±12.5°, 56.5±16.6°, 120.5°±25.1°, and 113.5°±25.4° respectively. Constant-Mur- ley score and FUSS increased from 33.5±9.9 and 50.9±7.6 to 62.8±8.1, and 81.7±7.0, respectively. The improvement in all measurements was significant. Conclusion For pnsterosuperior iMRCT, arthroscopic latissimus dorsi transfer with rotator cuff repair can decrease shoulder pain and improve shoulder function.