取自体阔筋膜动力化上关节囊重建治疗不可修复巨大肩袖撕裂的早期临床疗效观察

Early clinical effects of dynamic superior capsule reconstruction using autologous fascia lata grafts on irreparable massive rotator cuff tears

目的观察并评价取自体阔筋膜动力化上关节囊重建术(superior capsule reconstruction,SCR)治疗不可修复巨大肩袖撕裂的早期临床疗效。方法回顾性分析中国人民解放军陆军军医大学第一附属医院运动医学中心2019年9月—2021年4月收治的20例使用自体阔筋膜行动力化SCR和经典SCR治疗不可修复巨大肩袖撕裂患者。动力化SCR是在经典SCR的基础上将冈上肌肌腱残端缝合在自体阔筋膜上。本研究中,行动力化SCR患者10例(动力化SCR组),男性4例,女性6例;年龄51~82岁,平均67.0岁。经典SCR患者10例(经典SCR组),男性2例,女性8例;年龄50~68岁,平均59.0岁。两组均属于退变型巨大肩袖撕裂。术前及末次随访对比患者肩关节活动度改善情况,同时采用疼痛视觉模拟评分(visual analogue scale,VAS)、Constant评分、美国肩肘外科协会(American Shoulder and Elbow Surgeons,ASES)评分及Goutallier分级分别对肩关节疼痛、功能及脂肪浸润情况进行评价。结果20例均获随访,平均随访时间(19.3±7.6)个月[动力化SCR组和经典SCR组平均随访时间分别为(22.2±7.5)个月和(16.4±6.7)个月]。两组患者在年龄、性别、病程和随访时间方面比较差异无统计学意义(P>0.05)。动力化SCR组和经典SCR组患者平均病程分别为(28.2±15.0)个月和(20.4±9.5)个月;术前两组肩关节活动度、肩峰下间隙、VAS、Constant评分、ASES评分及Goutallier分级比较差异均无统计学意义(P>0.05);末次随访时两组肩关节前屈、外展、外旋和内旋活动度,肩峰下间隙,VAS,Constant评分,ASES评分均较术前获得显著改善。动力SCR组术后VAS[(1.5±0.7)分vs.(1.4±0.5)分,P=0.678]、末次随访时Constant评分[(84.7±10.2)分vs.(85.1±9.2)分,P=0.902]、ASES评分[(89.4±6.8)分vs.(87.8±6.7)分,P=0.505)]及肩峰下间隙[(9.8±1.9)mm vs.(10.0±3.0)mm,P=0.796]与经典SCR组比较差异无统计学意义;但动力化SCR患者术后末次随访脂肪浸润程度较经典SCR患者明显减少(P<0.05)。结论动力化SCR和经典SCR治疗不可修复巨大肩袖撕裂均可显著改善肩关节功能。与经典SCR相比,动力化SCR冈上肌脂肪化程度获得显著改善。

Objective To evaluate the early clinical effect of dynamic superior capsule reconstruction(SCR)using autologous fascia lata grafts in the treatment of irreparable massive rotator cuff tears.Methods Twen-ty patients with irreparable massive rotator cuff tears treated in Department of Sports Medicine Center,the First Affil-iated Hospital of Army Medical University from Sep.2019 to Apr.2021 were analyzed retrospectively,including 10 patients managed by dynamic SCR and the other 10 by classical SCR,respectively.Dynamic SCR was achieved by further suture of the remnant supraspinatus tendon to the autologous fascia lata based on the classical SCR.For the dynamic SCR group,there were 4 males and 6 females aged 51-82 years,mean 67.0 years;while for the classical SCR group,there were 2 males and 8 females aged 50-68 years,mean 59.0 years,revealing no significant difference between two groups.All cases were degenerated massive rotator cuff tears.Improvement of the shoulder range of motion was compared before operation and at the last follow-up.Also,visual analogue scale(VAS),Constant score,American Shoulder and Elbow Surgeons(ASES)score and Goutallier grade were adopted to evaluate the shoulder pain,function and fatty infiltration,respectively.Results All the 20 patients were followed up for(19.3±7.6)months,(22.2±7.5)months in dynamic SCR group and(16.4±6.7)months in classical SCR group,showing no significant difference(P>0.05).The average preoperative course of disease was(28.2±15.0)months and(20.4±9.5)months in dynamic and classical SCR groups,respectively(P>0.05).Comparison between dynamic and clas-sical SCR groups showed no significant differences regarding shoulder range of motion,subacromial space,VAS,Con-stant and ASES scores before surgery,but significant improvement in both groups at the last follow-up in comparison to before surgery.At the last follow-up,there was no statistical difference in subacromial space((9.8±1.9)mm vs.(10.0±3.0)mm;P=0.796),VAS score(1.5±0.7 vs.1.4±0.5,P=0.678),Constant score(84.7±10.2 vs.85.1±9.2,P=0.902),ASES score(89.4±6.8 vs.87.8±6.7,P=0.505),except for the Goutallier grade,which was less severe in dynamic SCR group(P<0.05).Conclusion Both dynamic and classical SCR can largely im-prove the shoulder function,and the former shows superiority in reducing fat infiltration.