关节镜下"三明治"补片上关节囊重建术治疗巨大不可修复性肩袖撕裂

Arthroscopic superior capsular reconstruction of irreparable massive rotator cuff tearsras using"Sandwich"patch graft

目的探讨关节镜下"三明治"补片(自体阔筋膜+LARS人工韧带+自体阔筋膜)重建上关节囊治疗巨大不可修复性肩袖撕裂的疗效。方法回顾性分析2016年12月至2018年10月采用"三明治"补片重建上关节囊的随访2年以上的巨大不可修复性肩袖撕裂患者29例,男12例、女17例;年龄(66.01±5.88)岁(范围55~77岁)。肩胛下肌肌腱完整13例、可修复16例;小圆肌均完整,三角肌功能完整;肩袖损伤Hamada分型2型11例、3型14例、4型4例。术后以患肩主动外展上举角度、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、美国加利福尼亚大学洛杉矶分校(University of California Los Angeles,UCLA)评分以及Constant-Murley评分评估肩关节疼痛及功能。以肩关节X线及MRI评估肩峰-肱骨头间距(acromiohumeral distance,AHD),判断补片愈合情况。结果全部病例均获得随访,随访时间(35.30±7.20)个月(范围24~46个月)。末次随访时患肩主动外展上举角度为158.45°±23.87°(范围70°~180°),较术前的92.59°±45.99°(范围20°~160°)提高,差异有统计学意义(t=6.190,P<0.001);ASES评分为(92.92±9.08)分(范围64~100分)、UCLA评分为(31.62±3.93)分(范围19~35分)、Constant-Murley评分为(85.83±8.44)分(范围68~94分),均较术前[分别为(30.69±12.99)分(范围68~95分)、(10.93±3.43)分(范围4~17分)、(39.62±12.68)分(范围14~55分)]提高,差异有统计学意义(t=21.145,21.348,16.333,P<0.001);VAS评分为(0.41±0.57)分(范围0~2分),较术前的(4.90±1.05)分(范围3~7分)降低,差异有统计学意义(t=20.267,P<0.001)。末次随访时MRI示AHD由术前(3.31±1.57)mm(范围1.10~6.60 mm)增加至(6.94±1.76)mm(范围3.0~10.8 mm),手术前后的差异有统计学意义(t=12.195,P<0.001)。26例补片获得愈合,愈合率89.7%(26/29);部分撕裂1例,完全撕裂2例(其中1例感染)。结论"三明治"补片重建上关节囊术后短期随访愈合率较高,可使肩关节功能早期恢复,是治疗巨大不可修复性肩袖撕裂的有效术式。

Objective:To investigate the effect of arthroscopic superior capsular reconstruction(ASCR)of irreparable massive rotator cuff tears(RCTs)using the"Sandwich"patch graft(autologous fascia lata+LARS artificial ligament+autologous fascia lata).Methods:The patients with irreparable massive RCTs who underwent ASCR by using"Sandwich"patch graft were retrospectively evaluated between December 2016 and October 2018.All cases were followed up more than two years.The pain and function of the shoulder were evaluated by visual analogue scale(VAS),active forward elevation(aFE),American Shoulder&Elbow Surgeons score(ASES),University of California Los Angeles(UCLA)score,and Constant-Murley score.The acromiohumeral distance(AHD)and patch healing were assessed by shoulder X-ray and MRI scan.Results:Twenty-nine patients(12 males and 17 females)were enrolled for final analysis.The average age was 66.0±5.88 years(range 55-77 years).The average length of follow-up was 35.3±7.20 months(range 24-46 months).The tendon of the subscapularis muscle was intacted in 13 cases and repairable in 16 cases.All patients'teres minor muscles were intact and the function of deltoid muscles was all complete.Based on Hamada classification of massive RCTs,11 cases with type 2,14 cases with type 3,and 4 cases with type 4.At the last follow-up visit,the AFE of the surgical shoulder was 158.45°±23.87°(range 70°-180°),which was significantly higher than before the surgery 92.59°±45.99°(range 20°-160°,t=6.190,P<0.001).The ASES score was 92.92±9.08(range 64-100),UCLA score was 31.62±3.93(range 19-35),and Constant-Murley score was 85.8±8.44(range 68-94),which were higher than those before the operation 30.69±12.99(range 68-95),10.93±3.43(range 4-17),39.62±12.68(range 14-55).There were significant differences between them,respectively(t=21.145,P<0.001;t=21.348,P<0.001;t=16.333,P<0.001).The VAS was 0.41±0.57(range 0-2 points),which was significantly lower than that of 4.90±1.05(range 3-7 points)before operation(t=20.267,P<0.001).At the last follow-up visit,MRI showed that the AHD increased from 3.31±1.57 mm(range 1.1-6.6 mm)to 6.94±1.76 mm(range 3.0-10.8 mm)significantly(t=12.195,P<0.001).Radiological outcomes were evaluated according to MRI,the total healing rate was 89.7%(26/29).There were two cases of complete tears,which including one case of infection and 1 partial tears.Conclusion:ASCR of irreparable massive RCTs using"Sandwich"patch graft showed the high healing rate in the short-term follow-up,which is possible to restore the shoulder functions early.It is an effective method for the treatment of irreparable massive RCTs.