肩袖关节侧部分撕裂的手术方式及疗效分析

Arthroscopic treatments for partial articular surface tendon avulsions and clinical outcomes analysis

目的探讨和分析关节镜下修补肩袖关节侧部分撕裂(PASTA)的手术方法,包括穿肌腱修补法和转全层修补法治疗Ellman 3级肩袖关节侧部分撕裂的疗效及优缺点。方法本次回顾性研究,分析了2015年3月至2017年6月期间因肩袖关节侧部分撕裂于南京医科大学第一附属医院骨科行手术治疗的全部患者,肩袖撕裂程度Ellman 3级(排除Ellman 1级和2级)的病例纳入本次研究,共42例。术中关节镜下根据滑囊侧残留肩袖组织的完整性、质地和张力等情况进行评估后,按手术修补方式分为穿肌腱修补组(肌腱组) 20例,和转全层修补组(全层组) 22例。肌腱组患者术中保留滑囊侧残留的肩袖组织,采用穿肌腱法修补肩袖;全层组患者术中清除滑囊侧残留的肩袖组织,直接转为全层撕裂,然后进行单排固定修补肩袖。术前、术后24 h及末次随访时对所有入组患者采用视觉模拟评分(VAS)进行疼痛评估。术前及术后末次随访时采用Constant-Murley肩关节评分(CSS)及洛杉矶加利福尼亚大学评分(UCLA)对所有入组患者进行肩关节功能评估。对比分析两组患者术后疗效及并发症发生情况,计数资料(性别、优势手和肩部外伤史等)采用χ~2检验,同一组内术前术后计量资料对比采用配对t检验。结果 42例患者均获得随访,随访时间6～30个月,平均(16±7)个月。两组患者术后24 h及末次随访时VAS评分均较术前明显降低,差异具有统计学意义(P <0. 05)。平均CSS评分从术前的(49. 6±5. 5)、(51. 3±5. 2)分别增加至(84. 2±7. 2)、(82. 6±6. 5),平均UCLA评分从术前的(18. 4±3. 2)、(17. 7±2. 3)分别增加至(32. 1±2. 2)、(31. 2±2. 2),差异具有统计学意义(P <0. 05)。两组患者术后24 h时疼痛评分对比存在差异,具有统计学意义(t=2. 8,P <0. 05)。比较两组患者末次随访时的疼痛评分及肩关节功能评分,差异均无统计学意义(P> 0. 05)。随访期间所有患者均未发生严重的术后并发症。结论对于Ellman 3级的肩袖关节侧部分撕裂,关节镜下穿肌腱修补法和转全层修补法均可获得较满意的疗效,而穿肌腱修补法可以保留滑囊侧的肩袖组织,足印区的修补更加符合解剖基础,从而达到更好的腱骨愈合。在两种手术方法均可以熟练掌握的前提下,穿肌腱修补是更为理想的手术方式。

Objective To study and analyze the efficacy of arthroscopic treatments of Ellman grade three partial articular surface tendon avulsions( PASTA),including the transtendon technique and completing technique. Methods The retrospective study collected 42 cases who had PASTA from March 2015 to June2017 in orthopedics department of the First Affiliated Hospital of Nanjing Medical University. The choice of surgical techniques was done according to the integrity,texture and tension of the bursal-side residual rotator cuff tissue during the surgery. Twenty cases received transtendon repair( group A),22 cases received completing repair( group B). The residual rotator cuff on the bursal side was preserved in group A while the rotator cuff intact was removed during operation in group B,then a standard single row reparing of full-thickness rotator cuff tear was done. To assess the extent of pain, the visual analogue scale( VAS) was evaluated preoperatively,in 24 h after the surgery and at the last follow-up. All the patients were evaluated by the Constant-Murley shoulder’s scalpel score( CSS) and the University of California Los Angeles score( UCLA)for shoulder function before the surgery and at the final follow-up. The postoperative complications were also compared in the two groups during the follow-up. Measurement data were analyzed using χ~2-test for parametric variables. Functional scores between the groups were analyzed using Students t-test for parametric variables.Differences between preoperative and postoperative outcomes were analyzed using the paired t-test for parametric variables. Results Forty-two cases were all followed up for six to 30 months,an average of( 16 ±7) months. The VAS scores in both groups in 24 h after surgery and at the last follow-up were significantly lower than those before operation( P < 0. 05). The mean CSS score increased from( 49. 6 ± 5. 5) and( 51. 3 ±5. 2) to( 84. 2 ± 7. 2) and( 81. 5 ± 7. 4) respectively,and the mean UCLA score increased from( 18. 4 ±3. 2) and( 17. 7 ± 2. 3) to( 32. 1 ± 2. 2) and( 31. 2 ± 2. 2) respectively;the differences were statistically significant( P < 0. 05). The difference in pain score between the two groups at 24 hours after the operation was significant( t = 2. 8,P < 0. 05). The differences were not significant in pain score and shoulder function score between the two groups before operation and at the last follow-up( P > 0. 05). No serious complication happened in all the patients during the follow-up. Conclusions For PASTA of Ellman grade three,both of the arthroscopic transtendon repair technique and the completing reparing technique could achieve satisfactory clinical results. The transtendon technique can rebuild the footprint anatomically and restore the integrity of the rotator cuff,which could be a more ideal surgical technique.