ASD联合三维重建技术治疗肩峰下撞击综合征疗效分析

Therapeutic effect analysis of ASD combined 3D reconstruction technique in the treatment of subacromial impingement syndrome

目的评价关节镜肩峰下间隙减压术(arthroscopic subacromial decompression,ASD)联合三维重建技术治疗肩峰下撞击综合征的疗效。方法回顾性分析自2014年1月至2015年6月在昌邑市人民医院采取ASD联合三维重建技术治疗的肩峰下撞击综合征患者共58例,术前应用三维重建技术对肩关节进行模拟成像,在其三维图像上测量同一患者患侧及健侧头顶肩峰距(head to acromion distance,HAD)、肱骨头的相对高度(the relative height of the humerus head,HH)、肩峰喙突距(acromion to coracoid distance,ACD)、结节肩峰距(tuberosity to acromion distance,TAD)。根据每个患者的测量结果,明确引起撞击的原因,在ASD中行个性化操作,精确磨除相应骨赘治疗肩峰下撞击综合征。采用美国加州大学(University of California,Los Angeles,UCLA)肩关节功能标准评价手术疗效。结果患侧HH的平均值为(0.87±0.19)cm,健侧HH的平均值为(1.08±0.21)cm,患侧较健侧距离低,差异有统计学意义(P<0.05);患侧HAD的平均值为(0.54±0.11)cm,健侧HAD的平均值为(0.66±0.15)cm,患侧较健侧的距离低,差异有统计学意义(P<0.05);患侧ACD的平均值为(2.90±0.39)cm,健侧ACD的平均值为(2.91±0.40)cm,患侧较健侧的距离差异无统计学意义(P>0.05);患侧TAD的平均值为(1.96±0.48)cm,健侧TAD的平均值为(1.95±0.45)cm,患侧较健侧的距离差异无统计学意义(P>0.05)。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(P<0.05),优良率为91.4%。结论术前采用三维重建技术测量肩关节HAD、HH、ACD、TAD可明确引起撞击的原因,为ASD提供精确的量化指标,术中可精确磨除相应骨赘,具有创伤小、精确度高、恢复快、并发症少等优点。

Background Acromial impingement syndrome was first proposed by Neer and is a common cause of shoulder pain and dysfunction.Currently,arthroscopic subacromial decompression(ASD)has become a preferred method for the treatment of subacromial impingement,which achieved satisfactory results and got a great promotion.In this study,58 patients with acromial impingement syndrome were treated with ASD combined with threedimensional reconstruction technique in Changyi people's hospital from January 2014 to June 2015 to evaluate the corresponding therapeutic effect.Methods(1)General information.Fifty-eight patients were involved in the group,including 26 males and 32 females;the age ranged from 27-81 years with an average of 56 years.All patients were treated conservatively for 3-6 months with poor outcomes,including rest,physical therapy,oral medication of NSAIDs and muscle strengthening exercise.(2)Preoperative measurement.The three-dimensional reconstruction technique was adopted to measure the relative height of the humerus head(HH),the head to acromion distance(HAD),the acromion to coracoid distance(ACD),the tuberosity to acromion distance(TAD).①HAD:the vertical distance between the highest point of the humeral head and the anterolateral acromial angle measured on the 3D reconstruction image of shoulder,marked as A1A2.②HH:the distance between the greater tuberosity of humeral and the vertex of humeral head on the 3D reconstruction image of shoulder,marked as B1B2.③ACD:the distance between the anterolateral acromial angle and the tip of coracoid process measured on the 3D reconstruction image of the shoulder with rotation of scapula,marked as C1C2.④TAD:the horizontal distance between the lateral margin of great tubercle of humerus and the outermost margin of acromion measured on the 3D reconstruction image of shoulder,marked as D1D2.(3)Surgical methods.①Individualized o p e r a t i o n d e s i g n.T h r o u g h p r e o p e r a t i v e m e a s u r e m e n t s o f H A D,H H,A C D,T A D a n d o t h e r anatomical structures of the affected and unaffected shoulder joints,the causes of subacromial impingement syndrome were clearly understood in order to perform individualized operation for the patient.If the visible subacromial osteophytes on preoperative images of 3-D reconstruction made HAD distance smaller than that of the uninjured side,the corresponding osteophytes could be removed intraoperatively based on the data measured for the uninjured side.This prevented the insufficient decompression caused by excessive or inadequate bone removal and the continuous existence of postoperative impingement syndrome.For patients with the ipsilateral HH much smaller than the contralateral HH on preoperative 3D reconstruction,osteophytes of the humeral greater tuberosity could be removed by accurate rubbing based on the measurement result.②Surgical procedures.Under general anesthesia,the patient was in beach chair position.The posterior approach was adopted regularly for examinations of glenohumeral joint and subacromial space.The decompression of subacromial space was performed after arthroscopic examination.Under the observation of arthroscopy,"feather like"rubbing was conducted medially from the anterolateral acromion using the motorizing bur.Individualized operation was performed based on the HAD data measured by preoperative 3D reconstruction to precisely removc the osteophytes on the inferior surface of acromion,and the thickness of removed osteophytes ranged from 5 to 8 mm.For patients with the ipsilateral HH much lower than the contralateral HH on preoperative 3D reconstruction,greater tuberosity plasty could be performed based on the measurement result.During the exploration,suture fixation should be carried out with suture anchors for partial tears of rotator cuff.After sufficient irrigation,hemostasis was performed carefully with radiofrequency ablation.The aseptic dressing was used for covering,and the drainage tube could be placed.The analgesic pump could be used postoperatively.(4)Evaluative criteria of therapeutic effect.The curative effect was evaluated by the shoulder functional score criteria of University of California,Los Angeles(UCLA).The total score of UCLA was 35 points,including pain for 10 points,function for 10 points,range of anteflexion for 5 points,muscle strength of anteflexion for 5 points and patient satisfaction for 5 points.34-35 points were considered excellent,29-33 points were good,and<29 points were poor.(5)Statistical analysis.The SPSS 17.0 software was used for data analysis and process.The measurement data were expressed as mean±standard deviation.The measurement data were compared with t test.P<0.05 was considered statistically significant.Results The average HH value for the affected side was(0.87±0.19)cm,which was lower than the average HH value for the unaffected side(1.08±0.21)cm,and the difference was statistically significant(P<0.05).The average HAD value for the affected side was(0.54±0.11)cm,which was lower than the average HAD value for the unaffected side(0.66±0.15),and the difference was statistically significant(P<0.05).The average ACD value for the affected side was(2.90±0.39)cm,and the corresponding value for the unaffected side was(2.91±0.40)cm.There was no statistical difference in between(P>0.05).The average TAD value was(1.96±0.48)cm for the affected side and was(1.95±0.45)cm for the unaffected side.There was no statistical difference in between(P>0.05).The average follow-up time was 16.4 month with a range of 12-24 months.The UCLA score was(16.8±4.1)points preoperatively and(32.4±1.5)points postoperatively,and the difference in between was statistically significant(P<0.05).According to the UCLA score,32 cases were excellent,21 cases were good and 5 cases were bad.The excellent and good rate was 91.4%.Conclusions The research of ASD combined with 3D reconstruction technique for the treatment of subacromial impingement syndrome has the following advantages:(1)Compared to the open surgery,this operation has small trauma,high accuracy,smaller and more beautiful skin incision,less postoperative pain and quick recovery;(2)Other intra-articular damages can be discovered and treated during surgery;(3)The attachment point of deltoid muscle is protected to avoid stripping.Thus,l ittle damage to the muscle is resulted;(4)The rotator cuff injury can be observed directly and sutured for fixation on time under arthroscopy;(5)The incidence of postoperative complications is low with short hospitalization,and the clinical effect is satisfactory.