反式全肩关节置换治疗不可修复性肩袖撕裂的临床应用及研究进展

Clinical practice and progression of reverse total shoulder arthroplasty treatment for irreparable rotator cuff tear

不可修复性肩袖撕裂(irreparable rotator cuff tear)在中老年人群中发病率高,严重影响患者的日常生活和活动能力。不可修复性肩袖撕裂通常由于长时间的磨损、退行性改变或急性外伤导致,且由于肌腱的退变和瘢痕化,使常规的修复手术,如关节镜下肩袖修补术、肌腱转位术、肩峰下球囊间隔术、上关节囊重建术等的临床疗效并不一致。反式全肩关节置换术(reverse total shoulder arthroplasty)颠倒了盂肱关节的球窝解剖结构,内移肱骨头旋转中心,远端化肱骨干,有助于增加外展时三角肌力臂,从而改善肩关节稳定性和活动范围。对肩关节力偶平衡失调影响肩关节功能的患者,采用反式全肩关节置换术能够充分募集三角肌肌力,有效改善因肩袖巨大缺损导致的肩关节功能障碍。盂侧假体的旋转中心及肱骨侧假体的倾角是影响假体稳定性的主要因素。反式全肩关节置换术不仅可以作为治疗老年不可修复性肩袖撕裂的初选方案,而且在其他治疗方案失败后仍可作为补救措施,两者的术后短期及中远期疗效均良好。但是手术的成功率和患者的满意度受多种因素影响。术后应重视反式全肩关节置换术后康复的阶段性目标及方法以确保患者合理地进行日常活动,避免对关节假体造成过度的压力或损伤。此外,对反式全肩关节置换术后可能出现的并发症,如肩胛盂切迹、肩关节不稳、假体周围骨折及假体感染等,需要通过精心的术前规划、术中操作技术和术后管理来预防,一旦出现需及时识别和正确处理。最后,有关反式全肩关节置换用于不可修复肩袖撕裂治疗的争议问题,如联合肌腱转位以改善外旋功能、修复肩胛下肌以增加内旋肌力以及手术年龄指征,需更多的临床研究和长期随访予以解决。以上结论为不可修复性肩袖撕裂患者的治疗提供了基于证据的指导,明确了反式全肩关节置换术治疗不可修复性肩袖撕裂的优势与注意事项,旨在为进一步优化治疗方案、提高患者生活质量、促进医学研究提供新思路。

Irreparable rotator cuff tear(IRCT)is highly prevalent among the middle-aged and elderly populations,significantly affecting patients'daily lives and functional capabilities.These tears often result from chronic wear and tear,degenerative changes,or acute trauma.Tendon degeneration and scarring make conventional repair surgeries,such as arthroscopic rotator cuff repair,tendon transfer procedures,subacromial bursectomy,and superior capsule reconstruction,yield inconsistent clinical outcomes.Reverse total shoulder arthroplasty(RTSA)reverses the anatomical structure of the glenohumeral joint,medially displaces the humeral head's center of rotation,and distally extends the humeral shaft.This configuration increases the deltoid moment arm during abduction,enhancing glenohumeral joint stability and range of motion.For patients with shoulder joint dysfunction caused by a disrupted force couple balance,this surgical approach can effectively harness the deltoid muscle's power,significantly improving shoulder joint function in the presence of massive rotator cuff defects.The center of rotation of the glenoid prosthesis and the inclination angle of the humeral prosthesis are key factors affecting the prosthesis's stability.RTSA serves not only as a primary treatment option for elderly patients with IRCT but also as a salvage measure after the failure of other treatment plans,demonstrating satisfactory outcomes in the mid to long term.The success rate of surgery and patient satisfaction are influenced by multiple factors.Postoperatively,it is crucial to focus on phased rehabilitation goals and methods following RTSA to ensure that patients can engage in daily activities without exerting undue stress or causing injury to the prosthetic joint.Additionally,potential complications after RTSA,such as glenoid notching,shoulder instability,periprosthetic fractures,and prosthetic joint infection,must be prevented through meticulous preoperative planning,intraoperative techniques,and postoperative management.Should these complications arise,they require timely identification and appropriate treatment.Finally,the contentious issues regarding the use of RTSA in treating IRCT-such as the combination of tendon transfer to improve external rotation,repair of the subscapularis to enhance internal rotation strength,and the indications for surgical age-necessitate further clinical research and long-term follow-up for resolution.These conclusions provide evidence-based guidance for treating patients with IRCT,clarify the advantages and considerations of RTSA in treating IRCT,and aim to offer new perspectives for optimizing treatment plans,improving patient quality of life,and promoting medical research.