反式全肩关节假体置换治疗巨大不可修复肩袖撕裂

Reverse total shoulder arthroplasty for irreparable massive rotator cuff tears

目的探讨反式全肩关节置换术(reverse total shoulder arthroplasty,RTSA)治疗巨大不可修复肩袖撕裂的临床治疗效果。方法对南京中医药大学附属医院2018年5月至2020年1月收治的采取RTSA治疗的13例巨大不可修复肩袖撕裂患者的临床资料进行回顾性分析。记录术前及最后一次随访时患者的肩关节前屈、外展、外旋活动,美国肩肘外科协会评分(American shoulder and elbow surgeons score,ASES)及美国加州大学洛杉矶分校(University of California at Los Angeles,UCLA)评分评估患者肩关节功能。并记录患者发生并发症的情况及影像学检查结果。术前行MR确定肩袖脂肪浸润程度,CT评价肩胛盂骨质情况及有无缺损,术后使用X线评估假体情况。结果13例患者均随访至少12个月以上。统计术前与术后12个月数据之间的关系,术后12个月肩关节前屈、外展、外旋活动,ASES评分和UCLA评分较术前明显提高,差异具有统计学意义(P<0.01)。随访期内13例患者中有1例患者因局部血肿在术后1周行切开血肿清除引流术,所有患者功能恢复良好。结论RTSA治疗巨大不可修复肩袖撕裂临床效果良好。

Background Massive rotator cuff tear was defined as a complete tear of at least two tendons or a tear size of over 5 cm.Massive irreparable rotator cuff tears often lead to shoulder dysfunction that can significantly affect daily activities.In chronic cases,rotator cuff tears are accompanied by retraction and atrophy of muscles and tendons,followed by muscle fat infiltration,making the rotator cuff irreparable.Rotator cuff tears are considered non-repairable and usually result in structural healing.Various surgical approaches have been used to treat massive irreparable rotator cuff tears,including arthroscopic combined biceps long head tendon fixation,rotator cuff partial repair,tendon transposition,and patch enhancement.However,none of these methods is the best treatment for massive irreparable rotator cuff tears.Their clinical results are not very reliable,and the incidence of postoperative complications increases over time.In patients with glenohumeral arthritis,arthroscopic repair or tendon transposition may be associated with residual pain and dysfunction.RTSA is an option for patients with or without\irreparable rotator cuff tear when the deltoid muscle is functioning well.RTSA was initially designed to improve upper limb elevation and relieve pain in patients with rotator cuff defects combined with glenohumeral arthritis.Since the development of RTSA,many clinical studies have demonstrated that RTSA is an effective treatment for rotator cuff arthropathy.Indications for RTSA have gradually expanded to other shoulder disorders,including irreparable rotator cuff tears that were previously treated differently.Currently,RTSA is the preferred treatment for elderly patients with massive irreparable rotator cuff tears.RTSA can relieve pain and improve shoulder function,thereby improving quality of life,but the prostheses'high complication rate and longevity are of concern.The implementation of RTSA in China is late,and the RTSA for irreparable massive rotator cuff tears is less experienced.Objective To investigate the clinical efficacy of reverse total shoulder arthroplasty in treating irreparable massive rotator cuff tear.Methods From May 2018 to January 2020,13 irreparable massive rotator cuff tear cases were treated in the Affiliated Hospital of Nanjing University of Chinese.The angles of anteflexion,abduction,external rotation,and the scores of ASES(American shoulder and elbow surgeons)and UCLA(University of California at Los Angeles)were recorded before surgery and at the final follow-ups to evaluate the shoulder joint function,and the complications and imaging results were documented as well.Preoperative MR was conducted to assess the degree of rotator cuff fat infiltration,CT was undertaken to evaluate the condition and defect of scapular glenoid bone,and postoperative radiographs were used to assess the status of the prosthesis.Results All patients were followed up for at least 12 months.The angles of anteflexion,abduction,and external rotation and the scores of ASES and UCLA after operation were remarkably improved compared to those before the procedure.There was a significant statistical difference(P<0.01).During the follow-up period,1 of the 13 patients underwent hematoma removal and drainage one week after surgery due to local hematoma,and all patients had good functional recovery.Conclusion RTSA has an excellent clinical effect on irreparable massive rotator cuff tears.