肱二头肌长头腱“L”形转位上关节囊与肩袖索联合增强重建术治疗巨大肩袖撕裂

The treatment of giant rotator cuff tear with enhanced reconstruction of the superior capsule and rotator cable by "L" shape transposition of long head of biceps tendon

目的 探讨肩关节镜下肱二头肌长头腱“L”形转位上关节囊与肩袖索联合增强重建术治疗巨大肩袖撕裂的临床疗效。方法 36例巨大肩袖撕裂患者均采用肩关节镜手术治疗,镜下将肱二头肌长头腱“L”形转位进行上关节囊与肩袖索联合增强重建,随后再修复残存的肩袖组织。记录患者手术情况及并发症;术前和术后采用肩关节主动活动度、疼痛视觉模拟评分(VAS)、美国肩肘外科(ASES)评分、Constant-Murley评分及复旦大学肩关节功能评分(FUSS)进行肩关节功能和疼痛评价;肩关节正位X线片和三维CT评估肩关节退变程度、肱骨近端移位距离(PHM);MRI评估重建组织结构完整情况。结果 所有患者手术顺利,21例(58%)行全层肩袖修复单排或双排缝合桥固定;15例(42%)行部分肩袖修复。25例肩胛下肌腱撕裂者使用单排技术修复。术中使用锚钉2~5枚,平均(3.8±1.4)枚。14例行肩峰有限成形术;12例行肱骨大结节成形术;10例同时行肩峰、肱骨大结节成形术。手术时间50~110 min,平均(83.21±21.57)min。穿刺口均甲级愈合,未呈现感染、脂肪液化、血管神经损伤等并发症。患者术后6、12个月,末次随访肩关节主动活动度,肩关节VAS、ASES、Constant-Murley、FUSS评分均较术前明显改善,且关节活动功能和各项评分随着随访时间延长呈持续改善(P<0.01);三维CT显示患者术后末次随访PHM较术前显著减少(P<0.01);MRI随访评估显示34例重建组织结构完整,愈合率达94.4%。结论 采用肩关节镜下肱二头肌长头腱“L”形转位上关节囊与肩袖索联合增强重建术治疗巨大肩袖撕裂可明显缓解疼痛及改善肩关节功能,再撕裂率较低,值得临床推广。

Objective To investigate the clinical effect of arthroscopic reconstruction of the superior capsule and rotator cable with "L" shape transposition of long head of biceps tendon in the treatment of giant rotator cuff tear.Methods Thirty-six patients with giant rotator cuff tears were included.All patients were treated by shoulder arthroscopy,in which the long head of the biceps tendon was "L" shaped transposed for joint reconstruction of the superior capsule and rotator cable,followed by repairing the remaining rotator cuff tissue.The patient’s surgical condition and complications were recorded.The active shoulder mobility,visual analogue score of pain(VAS),American Shoulder and Elbow Surgery(ASES) score,Constant-Murley score and Fudan University Shoulder Function Score(FUSS) were used for evaluating shoulder joint function and pain before and after surgery.Anteroposterior X-ray and three-dimensional CT were used to evaluate the degree of shoulder degeneration and proximal humeral displacement distance(PHM).MRI was used to assess the structural integrity of the reconstructed tissue.Results The operation was successful in all patients.Twenty-one patients(58%)underwent full rotator cuff repair with single-or double-row suture bridge fixation.Fifteen patients(42%) underwent partial rotator cuff repair.Subscapularis tendon tears were repaired using a single-row technique in 25 patients.Two to five anchor nails were used during surgery,with a mean of(3.8±1.4).Fourteen patients underwent limited acromioplasty.Twelve cases underwent humeral megacartilage,and 10 cases underwent both acromioplasty and humeral megacartilage.The operative times ranged from 50 to 110 min,with a mean of(83.21±21.57) min.The puncture openings healed grade A,and no complications such as infection,fat liquefaction or vascular nerve injury were found.At 6 and 12 months after surgery,the active shoulder mobility and shoulder VAS,ASES,Constant-Murley,and FUSS scores were significantly improved at the last follow-up compared with the preoperation.The joint mobility and scores showed continuous improvement with the extension of the follow-up time(P <0.01).3D CT showed a significant reduction in PHM at the last postoperative follow-up compared with the preoperative period(P<0.01).MRI follow-up evaluation showed that the reconstructed tissue was structurally intact in 34 cases,with a healing rate of 94.4%.Conclusion The treatment of giant rotator cuff tears by combined augmented reconstruction of the long head of biceps tendon with the rotator cable under shoulder arthroscopy can significantly relieve pain and improve shoulder joint function,and the re-tear rate is low,which is worthy of clinical promotion.