体格检查及磁共振对肩胛下肌撕裂的诊断价值研究

Study on the Diagnostic Value of Physical Examination and Magnetic Resonance Imaging in Subscapularis Muscle Tear

目的①比较单项肩关节体格检查及磁共振(MRI)对肩胛下肌腱撕裂的诊断价值;②探究联合体格检查对肩胛下肌腱撕裂的诊断价值。方法前瞻性收集2021年8月-2022年12月于石河子大学第一附属医院关节外科行肩关节镜手术的患者125例,以关节镜下诊断为金标准,所有患者术前均接受规范的肩关节体格检查及3.0T MRI检查,纳入研究的体格检查包括抬离试验(LOT)、压腹试验(BPT)、熊抱试验(BHT)、拿破仑试验(Napoleon)、离腹试验(BOS)、内旋衰减试验(IRLS)、0°内旋抗阻试验(IRRT0°)及90°内旋抗阻试验(IRRTM)。经Kappa检验比较单项体格检查的观察者间差异,计算灵敏度、特异度、Youden指数(Youden'sindex)、阳性预测值、阴性预测值、阳性似然比、阴性似然比、诊断比值比,绘制受试者工作特征(ROC)曲线,计算曲线下面积(AUC)以比较单项体格检查与3.0T MRI对肩胛下肌腱撕裂的诊断价值。选取AUC值最高的4项体格检查,分别计算2项、3项、4项体格检查串联及并联诊断的灵敏度、特异度、Youden指数、AUC以比较各项联合体格检查之间的诊断价值。最后选取具有最佳诊断效能的联合体格检查,比较其与MRI的诊断效能。结果①单项体格检查诊断肩胛下肌腱撕裂的灵敏度均小于70%,特异度均大于80%。IRRTM、LOT、Napoleon、BPT、IRLS、BOS、IRRT0°、BHT的灵敏度分别为61.29%、35.48%、29.03%、35.48%、25.81%、58.06%、51.61%、58.06%;8项体格检查按照AUC值从高到低排序为:IRRTM(0.748)、BOS(0.716)、BHT(0.700)、IRRT0°(0.689)、LOT(0.608)、BPT(0.603)、Napoleon(0.587)、IRLS(0.571);MRI诊断肩胛下肌腱撕裂的灵敏度、特异度、AUC分别为77.42%、84.04%、0.807。②选取IRRTM、BOS、BHT、IRRT0°进行串并联诊断试验。串联IRRTM+BOS、IRRTM+BOS+BHT、IRRTM+BOS+BHT+IRRT0°的诊断灵敏度分别为35.48%、16.13%、9.68%,特异度分别为97.87%、100.00%、100.00%,Youden指数分别为0.301、0.161、0.097;AUC值分别为0.683、0.613、0.548;并联IRRTM+BOS、IRRTM+BOS+BHT、IRRTM+BOS+BHT+IRRT0°的诊断灵敏度分别为83.87%、96.77%、100.00%;特异度分别为77.66%、64.89%、60.64%,Youden指数分别为0.615、0.617、0.606;AUC值分别为0.749、0.749、0.798。③并联IRRTM+BOS+BHT+IRRT0°及MRI的AUC值分别为0.798、0.807;比较两者的AUC,差异无统计学意义(P>0.05)。结论①单项体格检查诊断肩胛下肌腱撕裂的价值较有限,MRI相较于单项体格检查显示出较好的诊断效能;②联合体格检查有助于提高肩胛下肌腱撕裂的诊断价值,其中,并联IRRTM+BOS+BHT+IRRT0°对肩胛下肌腱撕裂的诊断价值最高;③并联IRRTM+BOS+BHT+IRRT0°与MRI具体相似的诊断价值。

Objective①To compare the diagnostic value of single shoulder joint physical examination and magnetic resonance imaging(MRI)in subscapular tendon tear;②To explore the diagnostic value of combined physical examination for subscapular tendon tear.Methods A total of 125 patients who underwent arthroscopic shoulder surgery in the Department of Joint Surgery,the First Affiliated Hospital of Shihezi University from August 2021 to December 2022 were prospectively collected.The arthroscopic diagnosis was used as the gold standard.All patients underwent standardized shoulder joint physical examination and 3.0 T MRI examination before surgery.The clinical tests included Lift Off Test(LOT),Belly Press Test(BPT),Bear Hug Test(BHT),Napoleon Test,Belly Off Sign(BOS),Internal Rotation Lag Sign(IRLS),Internal Rotation Resistance Test at 0°Abduction and 0°External Rotation(IRRT0°)and Internal Rotation Resistance Test at Maximum 90°Abduction and Maximum External Rotation(IRRTM).Kappa test was used to compare the inter-observer differences of clinical tests,and the sensitivity,specificity,Youden's index,positive predictive value,negative predictive value,positive likelihood ratio,negative likelihood ratio,and diagnostic odds ratio were calculated.Draw the receiver operating characteristics(ROC)curves and calculate the areas under the curve(AUC)to compare the diagnostic values of clinical tests and 3.0T MRI.The four clinical tests with the highest AUC values were selected,and the sensitivity,specificity,Youden’s index and AUC of serial and parallel diagnosis of two,three and four clinical tests were calculated to compare the diagnostic values between the combined clinical tests.Finally,the combined clinical test with the best diagnostic efficacy was selected and compared with MRI.Results The sensitivity of single physical examination in the diagnosis of subscapular tendon tear was less than 70%,and the specificity was more than 80%.The sensitivity of IRRTM,LOT,Napoleon,BPT,IRLS,BOS,IRRT0°and BHT were 61.29%,35.48%,29.03%,35.48%,25.81%,58.06%,51.61%and 58.06%,respectively.The eight physical examinations were ranked from high to low according to AUC values:IRRTM(0.748),BOS(0.716),BHT(0.700),IRRT0°(0.689),LOT(0.608),BPT(0.603),Napoleon(0.587),IRLS(0.571);the sensitivity,specificity and AUC of MRI in the diagnosis of subscapular tendon tear were 77.42%,84.04%and 0.807,respectively.②IRRTM,BOS,BHT,and IRRT0°were selected for series-parallel diagnostic tests,the results showed that the diagnostic sensitivities of series IRRTM+BOS,IRRTM+BOS+BHT,and IRRTM+BOS+BHT+IRRT0°were 35.48%,16.13%,and 9.68%,respectively;the specificities were 97.87%,100.00%,and 100.00%,respectively;the Youden indexes were 0.301,0.161,and 0.097,respectively;the AUC values were 0.683,0.613 and 0.548,respectively.The diagnostic sensitivities of parallel IRRTM+BOS,IRRTM+BOS+BHT and IRRTM+BOS+BHT+IRRT0°were 83.87%,96.77%and 100.00%,respectively;the specificity was 77.66%,64.89%and 60.64%,respectively;the Youden index was 0.615,0.617 and 0.606,respectively;the AUC values were 0.749,0.749,and 0.798,respectively.③The AUC values of parallel IRRTM+BOS+BHT+IRRT0°and MRI were 0.798 and 0.807,respectively,but there was no significant difference in AUC between the two groups(P>0.05).Conclusion①The value of single physical examination in the diagnosis of subscapular tendon tear is limited,and MRI shows better diagnostic efficacy than single physical examination.②Combined physical examination is helpful to improve the diagnostic value of subscapular tendon tear.Among them,parallel IRRTM+BOS+BHT+IRRT0°has the highest diagnostic value for subscapular tendon tear.The diagnostic value of parallel IRRTM+BOS+BHT+IRRT0°is similar to that of MRI.