关节镜下人工韧带“内支架”辅助下的自体阔筋膜桥接技术治疗巨大不可修复肩袖撕裂

Arthroscopic Fascia Lata Autograft Bridging Repair with Artificial Ligament “Internal Brace” Reinforcement for Irreparable Massive Rotator Cuff Tears

目的:探讨关节镜下人工韧带"内支架"辅助下的自体阔筋膜桥接技术治疗巨大不可修复肩袖撕裂的临床疗效。方法:回顾性分析2017年1月至2018年5月采用关节镜下阔筋膜补片桥接冈上肌治疗的不可修复性巨大肩袖撕裂患者16例。其中男7例、女9例,年龄61.4±6.4岁(49~69岁)。肩关节X线及MRI评估术后肩峰-肱骨头间距(acromiohumeral distance,AHD)及巨大不可修复肩袖愈合情况。采用疼痛视觉模拟评分(visual analogue scale,VAS)、美国肩肘外科协会(American Shoulder&Elbow Surgeons,ASES)评分、美国加州大学(University of California Los-Angeles,UCLA)肩关节评分以及Constant-Murley评分评估肩关节疼痛及功能。结果:所有患者均获得至少2年随访,平均33.8±6.4个月(24~41个月)。术后2年AHD为7.2±1.2 mm,较术前的4.0±1.3 mm增加,差异有统计学意义(t=16.495,P=0.000)。MRI显示15例患者自体阔筋膜补片获得愈合。术后2年,患肩疼痛VAS评分较术前降低(0.8±0.5分vs 6.6±1.0分),差异有统计学意义(t=19.734,P=0.000);患肩功能ASES评分、UCLA评分及Constant-Murley评分较术前明显提高(93.8±5.1分vs 48.6±11.4分;31.4±4.6分vs 11.9±3.5分;89.5±3.8分vs 42.5±12.6分),差异均有统计学意义(t=14.489,P=0.000;t=13.463,P=0.000;t=14.258,P=0.000)。术前冈上肌肌力2~4级,术后2年冈上肌肌力4~5级,改善明显。结论:人工韧带作为"内支架"保护能够促进自体阔筋膜补片早期愈合。

Objective To investigate the clinical outcomes of arthroscopic fascia lata bridging repair with artificial ligament"internal brace"reinforcement for irreparable massive rotator cuff tears.Methods Sixteen cases(7 male and 9 female) with irreparable massive rotator cuff and undergoing arthroscopic fascia lata bridging repair combined with"internal brace"reinforcement between Jan 2017 and May 2018 were retrospectively analyzed. Their ages ranged from 49 to 69,with an average of 61.4 ± 6.4.X-ray and magnetic resonance imaging(MRI) were performed to assess the acromiohumeral distance(AHD) and healing of the irreparable massive rotator cuff. The visual analogue scale(VAS),University of California Los Angeles(UCLA) score,Constan-Murley score and American Shoulder & Elbow Surgeons(ASES) score were measured before the surgery and at follow-up to evaluate the pain and function of shoulders.Results All cases were followed up for at least 2 years,with the mean of 33.8 ±6.4 months(range: 24~41 months). Two years after the surgery,the average AHD was 7.2 ± 1.2 mm,significantly higher than that of 4.0 ± 1.3 mm preoperatively(t=16.495,P=0.000). Meanwhile, MRI showed goodhealing of the fascia lata patches in 15 patients. The average VAS pain score decreased significantly from 6.6 ± 1.0 preoperatively to 0.8±0.5 postoperatively(t=19.734, P=0.000). Moreover,the average scores of ASES,UCLA and Constant-Murley were 93.8 ± 5.1,31.4 ± 4.6 and 89.5 ± 3.8 respectively,significantly higher than those(48.6 ± 11.4,11.9 ± 3.5 and 42.5 ± 12.6) before surgery(t=14.48,P=0.000;t=13.463, P=0.000;t=14.258,P=0.000). The supraspinatus strength improved from grade 2~4 before the operation to grade 4~5 at the follow-up two years later.Conclusion The artificial ligament can be used as the"internal brace"in superior capsular reconstruction to improve the early healing of autogenous fascia lata patches.