反肩关节置换术的疗效影响因素

Influencing factors on effectiveness of reverse total shoulder arthroplasty

目的 总结反肩关节置换术(reverse total shoulder arthroplasty,RTSA)疗效的影响因素,以期为临床提供参考。方法 广泛查阅国内外RTSA相关研究文献,从手术技术、肌肉情况、患者一般状况及其心理预期与生活方式方面总结可能影响疗效的因素。结果 对于手术技术,不同手术入路各有优势;肩胛盂切迹、骨长入不良、骨吸收增加与感染均会导致关节盂假体松动,肱骨侧假体颈干角与后倾角分别影响着肩胛盂切迹的发生与术后关节内、外旋活动范围。对于肌肉情况,小圆肌与三角肌质量对术后关节稳定有重要影响,适度增加三角肌张力可以改善术后关节活动度,术中缝合修复肩胛下肌腱可以改善关节疼痛、功能、活动范围和力量。对于患者一般情况,性别、年龄、身体质量指数均与术后关节功能与并发症发生有关,且不同职业与术后运动水平也会影响效果。退行性病变严重、术前功能较差、病程较长的患者对手术期望更低,对疗效满意度更高;不良生活方式会对疗效产生消极影响。结论 RTSA的疗效与手术技术、肌肉情况、患者一般状况及其心理预期、生活方式有关。术者应选择颈干角较小的肱骨侧假体以及较大的肩盂球并下移下倾放置,选择合适的手术入路配合引流消灭死腔以降低感染风险,术后患者应避免产生较高前后剪切力的活动,避免关节盂假体松动。此外,肱骨侧假体后倾角设计为10°~20°使术后关节内旋与外旋范围获得最佳平衡,保持合适三角肌张力以维持关节稳定与良好活动度,术中推荐缝合肩胛下肌腱。

Objective To summarize the influencing factors on the effectiveness of reverse total shoulder arthroplasty(RTSA),so as to provide reference for clinical treatment.Methods The related research literature of RTSA at home and abroad was extensively consulted,and the factors that may affect the effectiveness were summarized from the aspects of surgical technique,muscle condition,general condition of patients,psychological expectation,and lifestyle.Results For surgical techniques,different surgical approaches have their own advantages.The glenoid notch,poor bone ingrowth,increased bone resorption,and infection would lead to the loosening of glenoid prosthesis.In addition,the neck shaft angle and inclination angle of humeral prosthesis affect the occurrence of glenoid notch and the range of motion of joint internal/external rotation after operation,respectively.For muscle condition,the quality of teres minor and deltoid muscle has an important influence on joint stability after operation.Moderate increase of deltoid muscle tension can improve joint mobility after operation,and suture repair of subscapular tendon during operation can relieve joint pain and improve function,range of motion,and strength.For the general condition of patients,gender,age,and body mass index are all related to postoperative joint function and complications,and different occupations and postoperative exercise levels affect the recovery.The patients with severe degenerative diseases,poor preoperative function,and long disease duration have lower expectations and higher satisfaction with the effectiveness,and bad lifestyle has a negative impact on the effectiveness.Conclusion The effectiveness of RTSA is related to surgical technique,muscle condition,general condition of patients,psychological expectation,and lifestyle.In order to avoid the loosening of glenoid prosthesis,the operator should choose humeral prosthesis with small neck shaft angle and large glenoid ball and put them down andinclined inferiorly during operation, and choose appropriate approach to eliminate space with drainage to reduce the riskof infection. After operation, patients should avoid activities that generate high anterior and posterior shear forces. Inaddition, the humeral prosthesis with a inclination angle of 10°-20° can achieve the best balance between the range ofinternal rotation and external rotation after operation. Proper deltoid tension can maintain joint stability and good rangeof motion. Suture of subscapular tendon is recommended.