LafosseⅠ型肩胛下肌损伤修复与否对前上方肩袖损伤修复疗效的影响

The role of repair of Lafosse I subscapularis lesions in anterosuperior rotator cuff reconstruction

目的探讨LafosseⅠ型肩胛下肌损伤修复与否对前上方肩袖损伤修复疗效的影响。方法回顾性分析2016年1月至2017年10月间29例手术治疗冈上肌损伤合并LafosseⅠ型肩胛下肌损伤患者的病历资料,根据术中肩胛下肌是否修复分为两组。不修复组16例,男7例,女9例;年龄48~75岁,平均59.3岁;术中只修复冈上肌,不修复肩胛下肌。修复组13例,男5例,女8例;年龄45~72岁,平均57.2岁;术中修复冈上肌的同时修复肩胛下肌。主要观察指标包括疼痛视觉模拟评分(visual analogue scale,VAS)、美国肩肘外科(American Shoulder and Elbow Surgeons,ASES)评分、Constant-Murley评分、肩关节活动度和患者满意度。末次随访时复查MRI,应用Sugaya分级标准评价肩袖肌腱再撕裂情况。结果29例患者均获得随访,不修复组随访时间为(15.9±3.9)个月(10~22个月),修复组为(16.9±3.4)个月(10~21个月)。末次随访时不修复组VAS评分为(1.1±1.1)分、ASES评分为(88.4±4.0)分、Constant-Murley评分为(86.0±3.2)分;修复组VAS评分为(0.9±1.1)分、ASES评分为(89.6±2.9)分、Constant-Murley评分为(87.5±2.6)分,两组的差异均无统计学意义(P>0.05)。末次随访时不修复组患者肩关节前屈上举活动度为150.3°±17.3°,体侧外旋活动度为41.6°±16.0°,内旋活动度达L2;修复组患者肩关节前屈上举活动度为148.1°±16.3°,体侧外旋活动度为43.9°±9.2°,内旋活动度达L1。两组患者末次随访时各观察指标均较术前明显改善(P<0.001),但两组间的差异均无统计学意义(P>0.05)。末次随访时复查MRI示再撕裂3例,再撕裂发生率为10.34%(3/29),不修复组2例、修复组1例。术后再撕裂的3例患者末次随访时肩关节ASES评分为(85.3±3.1)分,较术前(41.0±5.2)分明显提高,差异有统计学意义(t=12.74,P<0.001);前屈上举活动度为131.67°±5.8°,较术前81.7°±11.5°明显提高,差异有统计学意义(t=6.708,P=0.003)。再撕裂患者中1例(不修复组)接受再次手术治疗后症状消失,功能改善。不修复组与修复组患者术后满意度分别为93.7%和92.3%。结论对于合并冈上肌肌腱损伤的LafosseⅠ型肩胛下肌损伤术中修复肩胛下肌与否短期内疗效相当,不影响前上方肩袖损伤的修复疗效。

Objective To observe the effect of Lafosse I subscapularis lesion repair on the reconstruction of anterosuperior rotator cufftear.Methods A retrospective analysis was performed on patients who underwent surgical treatment of the supraspinatus torn combined with Lafosse I subscapularis lesion from January 2016 to October 2017. It was divided into two groups according to the subscapularis lesion was repaired or not. There were 16 cases in non-repaired group, 7 males and 9 females, aged from 48 to 75 years (average, 59.3 years). In this group, supraspinatus repair and subscapularis debridement with no repair were done. There were 13 cases in repaired group, 5 males and 8 females, aged from 45 to 72 years (average, 57.2 years). In this group, both supraspinatus and subscapularis were repaired. MRI was performed at last follow-up. The pain analogue scale (VAS), American Shoulder & Elbow Surgeons (ASES) score, Constant-Murley score and range of motion (ROM) were recorded at the last follow-up. Patients' satisfaction was recorded.Results Twenty-nine patients had been followed up. Patients in non-repaired group were followed up 15.9±3.9 months (range 10-22 months), and patients in repaired group were followed up 16.9±3.4 months (range 10-21 months). At the last follow-up, VAS, ASES score, and Constant-Murley score of non-repaired group were 1.1±1.1, 88.4±4.0 and 85.9±3.2 respectively. VAS, ASES score, and Constant-Murley score of repaired group were 0.9±1.1, 89.6±2.9 and 87.5±2.6 respectively. VAS (t=0.342, P=0.735), ASES score (t=-0.941, P=0.355) and Constant-Murley score (t=-1.392, P=0.175) showed no significant difference between non-repaired group and repaired group. At the last follow-up, forward flexion of affected shoulder in non-repaired group was 150.3°±17.3°, external rotation was 41.6°±16.0°, and internal rotation was L2 level;Forward flexion in repaired group was 148.1°±16.3°, external rotation was 43.9°±9.2°, and internal rotation was L 1 level, which were improved significantly compared with those pre-operation. Forward flexion, external rotation, and internal rotation showed no statistically significant difference between non-repaired group and repaired group. 3 patients were found to have rotator cuff re-tear by MR examination. The re-tear rate was 10.34% (3/29). There were 2 cases in non-repaired group and 1 case in repaired group. At the last follow-up, the ASES score of re-tear patients was 85.3±3.1, which was better than preoperative 41.0±5.2 (t=12.74, P<0.001). Forward flexion 131.67°±5.8° was better than preoperative 81.7°±11.5° (t=6.708, P<0.001). One re-tear patient (in non-repaired group) received reoperation and got pain relief. The satisfaction of non-repaired group and repaired group were 93.7% and 92.3%, respectively.Conclusion For type I subscapularis lesion combined with supraspinatus injury, wheter type I subscapularis lesion was repaired or notdidn't affect the repair effect of the anterosuperior rotator cuff tear in short-term follow-up.