陳建海 張一翀 張殿英 付中國(guó) 楊明 黨育 姜保國(guó)

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·論著·

肩關(guān)節(jié)鈣化性肌腱炎的關(guān)節(jié)鏡治療及急慢性期療效比較

陳建海 張一翀 張殿英 付中國(guó) 楊明 黨育 姜保國(guó)

目的 評(píng)估關(guān)節(jié)鏡下清除鈣化性肌腱炎肩袖鈣化病灶的治療效果，探討急性期組與慢性期組手術(shù)治療后的療效差別。方法 收集北京大學(xué)人民醫(yī)院創(chuàng)傷骨科2009年9月至2014年6月收治的鈣化性肌腱炎病例，符合標(biāo)準(zhǔn)者28例。按照發(fā)病至手術(shù)時(shí)間的不同分為急性期組和慢性期組，比較兩組術(shù)后Constant評(píng)分提升幅度，SST問(wèn)卷增長(zhǎng)個(gè)數(shù)，前屈、外旋角度改善及VAS評(píng)分下降的情況。結(jié)果 急性期組在術(shù)后Constant評(píng)分(t=3.242,P=0.003)、SST問(wèn)卷完成個(gè)數(shù)(t=2.080,P=0.048)、前屈角度(t=2.08,P=0.048)及VAS評(píng)分(t=2.394,P=0.024)四方面改善程度優(yōu)于慢性期組，而兩組在外旋角度改善方面差異無(wú)統(tǒng)計(jì)學(xué)意義(t=0.764,P=0.452)。結(jié)論 關(guān)節(jié)鏡下鈣化灶清除可以顯著改善患者肩關(guān)節(jié)功能、緩解疼痛。急性期患者與慢性期患者臨床療效相當(dāng)。

肩關(guān)節(jié)；肌腱炎；關(guān)節(jié)鏡；手術(shù)治療

肩袖鈣化性肌腱炎是引起肩痛的常見(jiàn)疾病之一，多發(fā)于30～50歲人群[1]，女性較多見(jiàn)[2]。鈣化性肌腱炎急性發(fā)作時(shí)患者表現(xiàn)為無(wú)明顯誘因出現(xiàn)的肩關(guān)節(jié)持續(xù)性劇烈疼痛，癥狀嚴(yán)重時(shí)甚至需要到急診尋求治療。多數(shù)急性發(fā)作患者可以通過(guò)保守治療獲得較為滿(mǎn)意的效果；但對(duì)于保守治療無(wú)效或癥狀持續(xù)不緩解，嚴(yán)重影響工作和生活的患者，手術(shù)直接清除鈣化灶是公認(rèn)的有效治療方法。近年來(lái),隨著肩關(guān)節(jié)鏡技術(shù)的不斷發(fā)展,關(guān)節(jié)鏡下清除鈣化物成為一種常規(guī)手術(shù)方法，也獲得了很好的治療效果[3-4]。我們回顧性評(píng)估關(guān)節(jié)鏡下清除鈣化性肌腱炎肩袖鈣化灶的治療效果，并探討急、慢性期患者手術(shù)治療后的肩關(guān)節(jié)功能改善情況。

資 料 與 方 法

一、一般資料

收集本院2009年9月至2014年6月收治的鈣化性肌腱炎病例。入選標(biāo)準(zhǔn)：(1)患者有劇烈肩關(guān)節(jié)疼痛的病史；(2)經(jīng)保守治療無(wú)效；(3)行關(guān)節(jié)鏡手術(shù)的患者。排除標(biāo)準(zhǔn)：(1)合并肩袖損傷的患者；(2)行切開(kāi)手術(shù)的患者。最終符合入選標(biāo)準(zhǔn)者28例。以急性發(fā)病到行關(guān)節(jié)鏡下鈣化灶清除術(shù)的時(shí)間不同分為急性期組和慢性期組。初次肩痛發(fā)作后至行關(guān)節(jié)鏡下鈣化灶清除術(shù)病程≤3個(gè)月的患者為急性期組；初次肩痛發(fā)作至行關(guān)節(jié)鏡下鈣化灶清除術(shù)病程>3個(gè)月，且經(jīng)保守治療仍未好轉(zhuǎn)或反復(fù)發(fā)作者為慢性期組。28例患者均有不同程度的患側(cè)疼痛及肩關(guān)節(jié)活動(dòng)受限。所有患者術(shù)前均行影像學(xué)檢查，根據(jù)X線片判斷肩關(guān)節(jié)鈣化灶大小、形態(tài)，了解肩峰形態(tài)。肩部X線片顯示肩峰下及偏外側(cè)的滑囊內(nèi)肩袖區(qū)有類(lèi)橢圓形或長(zhǎng)條形的高密度云霧狀鈣化影(圖1)。急性期患者共10例，年齡38～68歲，平均52.6歲，其中左肩5例，右肩5例。癥狀均為急性肩痛，呈針刺樣感，伴局部皮溫增高，肩部明顯壓痛，肩關(guān)節(jié)活動(dòng)嚴(yán)重受限且影響生活。術(shù)前X線片均可見(jiàn)肩峰下肩袖區(qū)高密度鈣化影。慢性期患者18例，年齡40～73歲，平均55.5歲；其中左肩7例，右肩11例，所有患者有劇烈肩痛史，劇烈疼痛持續(xù)一段時(shí)間后疼痛程度有所減輕，但一直沒(méi)有消失，肩痛時(shí)輕時(shí)重，肩關(guān)節(jié)功能明顯受限，影響正常生活。

圖1 鈣化性肌腱炎X線片表現(xiàn)

圖2 針頭穿刺鈣化灶 圖3 錨釘縫線穿過(guò)切開(kāi)的肌腱 圖4 縫線打結(jié)，完成肩袖修復(fù)

二、手術(shù)方法

所有手術(shù)由北京大學(xué)人民醫(yī)院副主任醫(yī)師或主任醫(yī)師完成。均采用全身麻醉、沙灘椅體位，術(shù)前做好體表標(biāo)記。關(guān)節(jié)鏡經(jīng)后方入路置入，檢查盂肱關(guān)節(jié)腔。通常關(guān)節(jié)囊內(nèi)壁有嚴(yán)重炎性滑膜增生充血，部分關(guān)節(jié)活動(dòng)受限，患者肩袖間隙攣縮，盂肱中韌帶增厚，肩袖結(jié)構(gòu)均完整。清理關(guān)節(jié)腔內(nèi)滑膜組織，松解肩袖間隙和盂肱中韌帶。使用穿刺針頭經(jīng)肩峰外緣穿刺岡上、岡下肌腱，尋找鈣化灶位置，如果針頭刺到鈣化灶，針頭尖部可以看到鈣化物(圖2)。確定鈣化灶位置后經(jīng)過(guò)針頭引入1枚PDS線作為標(biāo)記。然后將關(guān)節(jié)鏡轉(zhuǎn)入到肩峰下間隙，常?？梢钥吹矫黠@的肩峰下滑膜增生充血，有時(shí)可以在滑膜上看到已經(jīng)流出的鈣化物。使用刨刀徹底清理肩峰下滑膜，射頻刀止血，清晰暴露肩袖滑膜側(cè)結(jié)構(gòu)。通過(guò)縫線標(biāo)記定位好鈣化灶位置，而后用刀片順著肌腱纖維的走行切開(kāi)肌腱顯露病灶。使用刮勺清除鈣化灶，可以看到逸出的鈣化物似牙膏狀物質(zhì)，在肩峰下間隙內(nèi)彌散后呈“暴風(fēng)雪”征象。清除鈣化灶時(shí)應(yīng)盡量避免肩袖遭受進(jìn)一步破壞，徹底清除鈣化灶后再次仔細(xì)探查肩袖肌腱的缺損情況，對(duì)于鈣化灶巨大、涉及肌腱深度超過(guò)50%或者肩袖足印骨面暴露時(shí)，應(yīng)用1枚4.5 mm縫合錨進(jìn)行肩袖修復(fù)(圖 3，4)。9例患者術(shù)中進(jìn)行了肩袖修復(fù)。如合并肩峰下骨贅需徹底去除，有8例患者同時(shí)行肩峰成形術(shù)。

三、術(shù)后康復(fù)及評(píng)估

術(shù)后即對(duì)患肢進(jìn)行頸腕吊帶懸吊固定，術(shù)后1周內(nèi)予以適當(dāng)?shù)谋笙[，并開(kāi)始用健側(cè)手協(xié)助被動(dòng)運(yùn)動(dòng)肩關(guān)節(jié)，并逐漸增加活動(dòng)范圍。1周后逐步進(jìn)行主動(dòng)活動(dòng)，6 周后進(jìn)行肩關(guān)節(jié)抗阻力訓(xùn)練并行牽拉治療，術(shù)后3個(gè)月活動(dòng)范圍可達(dá)到正常，并可基本恢復(fù)日常生活。對(duì)合并有肩袖修補(bǔ)手術(shù)的患者應(yīng)在術(shù)后6周進(jìn)行主動(dòng)鍛煉，以免修補(bǔ)部位的錨釘松動(dòng)或再度撕裂。每位患者術(shù)前、術(shù)后常規(guī)進(jìn)行Constant評(píng)分，簡(jiǎn)明肩關(guān)節(jié)評(píng)分(SST)，肩關(guān)節(jié)活動(dòng)范圍檢查和VAS疼痛評(píng)分。

四、統(tǒng)計(jì)學(xué)分析

應(yīng)用 SPSS 15.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，對(duì)手術(shù)前后數(shù)據(jù)進(jìn)行配對(duì)資料t檢驗(yàn),P<0.05為差異具有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

共28例患者納入本項(xiàng)回顧性研究，術(shù)后隨訪6～33個(gè)月(平均18.8個(gè)月)。術(shù)后定期復(fù)查X線片，均顯示鈣化點(diǎn)消失。所有病例均在治療前以及術(shù)后隨訪時(shí)進(jìn)行Constant評(píng)分、SST問(wèn)卷評(píng)估、肩關(guān)節(jié)活動(dòng)范圍檢查以及VAS評(píng)分(表1，2)。10例急性期患者，Constant評(píng)分治療前平均為51.36分，治療后平均為88.16分，平均增長(zhǎng)約36.80分。其中前屈上舉角度增長(zhǎng)約77.00°，外旋角度增長(zhǎng)約18.50°。SST問(wèn)卷治療前回答“是”的問(wèn)題平均為5.02個(gè)，治療后回答“是”的問(wèn)題平均為9.32個(gè)，平均增長(zhǎng)約4.30個(gè)。VAS評(píng)分治療前平均為9.12分，治療后平均為4.62分，平均下降約4.50分。18例急性期患者，Constant評(píng)分治療前平均為63.70分，治療后平均為88.03分，平均增長(zhǎng)約24.33分。其中前屈上舉角度增長(zhǎng)約66.39°，外旋角度增長(zhǎng)約15.28°。SST問(wèn)卷治療前回答“是”的問(wèn)題平均為6.33個(gè)，治療后回答“是”的問(wèn)題平均為9.66個(gè)，平均增長(zhǎng)約3.33個(gè)。VAS評(píng)分治療前平均為7.30分，治療后平均為4.19分，平均下降約3.11分。

表1 急、慢性期患者手術(shù)前后評(píng)分及肩關(guān)節(jié)活動(dòng)范圍)

表2 急、慢性期患者手術(shù)后評(píng)分及肩肘關(guān)節(jié)活動(dòng)范圍改善程度)

本研究中，28例鈣化性肌腱炎患者經(jīng)關(guān)節(jié)鏡下鈣化灶清除術(shù)后，肩關(guān)節(jié)功能均有不同程度的改善；且急性期鈣化性肌腱炎經(jīng)手術(shù)治療后Constant 評(píng)分提升幅度(t=3.242,P=0.003)、SST增長(zhǎng)個(gè)數(shù)(t=2.080,P=0.048)、前屈上舉角度改善(t=2.08,P=0.048)及疼痛緩解程度方面(t=2.394,P=0.024)明顯高于慢性期。差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。本研究中共有9例行肩袖修復(fù)，其中急性期2例，占急性期病例數(shù)的20%；慢性期7例，約占慢性期病例數(shù)的38.9%。

討 論

文獻(xiàn)報(bào)道肩袖鈣化性肌腱炎的發(fā)病率在2.7%～20%。肩袖鈣化灶可出現(xiàn)在任意的肌腱，尤以岡上肌腱的發(fā)病最為常見(jiàn)[1-2，5]。目前肩袖鈣化性肌腱炎病因尚不明確，爭(zhēng)論較大。多數(shù)認(rèn)為其發(fā)生與肩袖退行性改變、肩袖乏血管區(qū)、代謝紊亂及細(xì)胞介入調(diào)節(jié)反應(yīng)等因素有關(guān)。岡上肌在上臂外展、上舉的起動(dòng)運(yùn)動(dòng)及穩(wěn)定盂肱關(guān)節(jié)方面均起重要作用，是肩袖肌群中退變發(fā)生最早的肌肉。Codman[6]在1934年提出岡上肌腱在大結(jié)節(jié)止點(diǎn)近側(cè)l cm范圍是乏血管區(qū)，血供最差，受應(yīng)力作用的影響最大，也是引起退變的主要原因，在退變的基礎(chǔ)上，進(jìn)一步局部鈣鹽代謝異常導(dǎo)致鈣鹽沉著，形成岡上肌腱鈣化性肌腱炎。Uhthoff等[7]根據(jù)鈣化性肌腱炎的病理過(guò)程將其分為三期。第一期為鈣化前期，此期無(wú)癥狀，肌腱組織發(fā)生纖維軟骨化生，即由膠態(tài)的致密結(jié)締組織被半固態(tài)的軟骨組織替代，這種刺激物是鈣化前的早期階段，患者通常沒(méi)有臨床癥狀。第二期為鈣化期，又可分為鈣化形成期、靜止期和吸收期。鈣化形成期，肌腱內(nèi)發(fā)生軟骨細(xì)胞介導(dǎo)的鈣化，形成鈣化物沉積，此時(shí)可能無(wú)癥狀或有不同程度的疼痛。當(dāng)膠原纖維組織包圍鈣化中心而沒(méi)有出現(xiàn)炎癥征象時(shí)即進(jìn)入靜止期,提示鈣質(zhì)沉積過(guò)程的終結(jié)。然后是吸收期，鈣沉積的周邊出現(xiàn)血管通道，接著發(fā)生鈣的吸收。此階段可出現(xiàn)極度的疼痛，患者多在此時(shí)開(kāi)始尋求治療。此時(shí)的鈣沉積有些像奶油或牙膏。當(dāng)鈣沉積吸收后，死腔有肉芽組織填充。第三期為鈣化后期。此期肉芽組織轉(zhuǎn)變?yōu)槌墒斓哪z原組織，纖維沿著與肌腱長(zhǎng)軸一致的應(yīng)力線排列，恢復(fù)正常的肌腱結(jié)構(gòu)。此期疼痛顯著減退。

急性鈣化性肌腱炎有如下臨床特點(diǎn)：(1)起病急，疼痛劇烈，患者能指出具體的發(fā)病時(shí)間，甚至需要到急診就診，患者有明顯夜間痛；(2)肩關(guān)節(jié)通常無(wú)法耐受活動(dòng)，各個(gè)方向活動(dòng)明顯受限；(3)受累區(qū)域常有壓痛；(4)保守治療后癥狀逐漸緩解，部分患者保守治療效果不理想。因此患者常積極尋求進(jìn)一步治療。急性期病灶多處于病理分期的鈣化期，此期鈣化灶已經(jīng)形成，病灶較為完整，易徹底清除。且鈣沉積的周邊出現(xiàn)血管通道，接著巨噬細(xì)胞及多核巨細(xì)胞等炎性細(xì)胞參與吸收過(guò)程，此階段可出現(xiàn)極度的疼痛及嚴(yán)重的功能受限，因此術(shù)前評(píng)分較低。如在此期將病灶清除，不但阻止病情進(jìn)一步進(jìn)展，而且急性期患者功能評(píng)分提升幅度更大，功能改善更為顯著。這就解釋了為什么本研究中急性期組患者較慢性期具有更明顯的療效。而對(duì)于鈣化性肌腱炎的急、慢性期的準(zhǔn)確界定，目前國(guó)內(nèi)外尚缺乏客觀、統(tǒng)一的標(biāo)準(zhǔn)。本研究根據(jù)患者的病程長(zhǎng)短進(jìn)行分期，視初次肩痛發(fā)作后病程≤3個(gè)月的患者為急性期組；而初次肩痛發(fā)作>3個(gè)月，且經(jīng)保守治療仍未好轉(zhuǎn)或反復(fù)發(fā)作者為慢性期。這實(shí)際上是一種主觀分期，但按照本研究提出的分期，患者臨床表現(xiàn)明顯不同，治療內(nèi)容也有差異，比如在慢性期組有更多的患者需要進(jìn)行肩袖修復(fù)和肩峰成形，這可能提示慢性期患者肩袖病變是導(dǎo)致疼痛反復(fù)發(fā)作的重要原因。

雖然肩袖鈣化性肌腱炎有很強(qiáng)的自愈傾向,但是這個(gè)自愈的過(guò)程很容易受阻,且引起劇烈疼痛[8]。對(duì)于手術(shù)治療的適應(yīng)證目前仍存在爭(zhēng)議，多數(shù)患者可通過(guò)藥物、物理治療等方法獲得滿(mǎn)意的效果[3]。調(diào)查顯示仍有部分患者經(jīng)保守治療無(wú)效。Rochwerger等[9]報(bào)道的手術(shù)成功的案例，在進(jìn)行切開(kāi)鈣化灶清除術(shù)以及肩峰成形術(shù)后，經(jīng)過(guò)23個(gè)月的隨訪期，Constant評(píng)分由51.36分上升至88.16分。切開(kāi)手術(shù)的倡導(dǎo)者認(rèn)為這種手術(shù)更為簡(jiǎn)單，且直視下可以較容易地修補(bǔ)肩袖。但隨著技術(shù)的發(fā)展，自1987年關(guān)節(jié)鏡手術(shù)同樣可以縮短住院時(shí)間及迅速恢復(fù)[10]。對(duì)于鈣化性肌腱炎，關(guān)節(jié)鏡的優(yōu)勢(shì)在于損傷小、恢復(fù)快，且能避免三角肌止點(diǎn)的破壞，還能對(duì)盂肱關(guān)節(jié)以及肩峰下間隙內(nèi)的損傷一并處理。通常在肩袖關(guān)節(jié)面?zhèn)茸阌^(qū)附近可以見(jiàn)到草莓紅斑，這代表了區(qū)域血管的增生。鈣化沉積灶常見(jiàn)于岡上肌，距離大結(jié)節(jié)附著點(diǎn)1.5～2 cm[11]。當(dāng)鈣化灶較難明確時(shí)，需使用硬膜外穿刺針定位。有時(shí)術(shù)中透視對(duì)于定位鈣化灶也是有幫助的。一旦確定鈣化灶的位置，就可使用關(guān)節(jié)鏡下的刀片順著肌腱纖維的走行切開(kāi)并清除病灶。在手術(shù)最后階段可以對(duì)盂肱關(guān)節(jié)及肩峰下間隙進(jìn)行沖洗，防止鈣化灶的殘留。這對(duì)于防止繼發(fā)肩關(guān)節(jié)僵硬是非常有效的，因?yàn)殛P(guān)節(jié)僵硬在鈣化性肌腱炎術(shù)后較為常見(jiàn)，約占9%～15%[12-13]。多數(shù)學(xué)者認(rèn)同術(shù)中清除鈣化灶的必要性，但對(duì)于是否進(jìn)行肩峰下成形目前爭(zhēng)議較大。Molé等[12]認(rèn)為對(duì)于微小鈣化灶有必要行肩峰成形術(shù)，也有學(xué)者認(rèn)為行肩峰下減壓可以促進(jìn)鈣化灶的吸收[14]。但也有人認(rèn)為這對(duì)手術(shù)最終效果沒(méi)有影響[15-17]。我們認(rèn)為，對(duì)于慢性期患者，很難區(qū)分疼痛是由鈣化灶還是肩峰下撞擊引起。我們?cè)谛g(shù)前常規(guī)拍攝岡上肌出口位X線片，術(shù)中如發(fā)現(xiàn)肩峰下表面有撞擊磨損表現(xiàn)，肩峰呈Ⅱ型或Ⅲ型，則行前肩峰成形術(shù)。但這仍缺乏較為確切的理論依據(jù)，仍需今后進(jìn)一步的深入研究。

Romain等[4]認(rèn)為關(guān)節(jié)鏡清理術(shù)殘留的鈣化物可逐漸被吸收，對(duì)最終療效無(wú)明顯影響。而Giuseppe等[3]卻認(rèn)為鈣化物殘留與術(shù)后疼痛關(guān)系密切。本文作者認(rèn)為對(duì)于鈣化灶應(yīng)盡量清除，少量殘留不會(huì)影響臨床癥狀的恢復(fù)。鈣化灶清除后在肩袖肌腱內(nèi)遺留空隙，造成部分性肩袖損傷。Maier等[15]認(rèn)為對(duì)于清理鈣化灶產(chǎn)生的較大的肩袖損傷，需進(jìn)行縫合，對(duì)于小的肩袖損傷可不予處理。我們?cè)谛g(shù)中注意控制清創(chuàng)范圍，對(duì)于損傷滑囊面深度超過(guò)肩袖肌腱厚度1/2，或者肩袖足印骨面暴露的患者，為防止術(shù)后肩袖斷裂，影響肩關(guān)節(jié)功能，需行肩袖修補(bǔ)術(shù)。本組病例中有9例行肩袖修補(bǔ)，其中急性期2例，占急性期病例數(shù)的20%；慢性期7例，約占慢性期病例數(shù)的38.9%。術(shù)后功能均恢復(fù)良好。本研究中慢性期行肩袖修補(bǔ)患者比例較大，原因可能是多方面的，鈣化灶會(huì)引起癥狀，肩袖退變性損傷也會(huì)引起癥狀，慢性期患者常伴發(fā)肩袖退變性損傷，這是進(jìn)行肩袖修復(fù)比例高于急性期的一個(gè)原因。

結(jié)論：肩袖鈣化性肌腱炎是引起急性肩痛的常見(jiàn)疾病之一。當(dāng)癥狀嚴(yán)重影響日常生活，且保守治療無(wú)效時(shí)，盡早行關(guān)節(jié)鏡下鈣化灶清理術(shù)可取得理想的預(yù)后。

[1] Depalma AF,Kruper JS.Long-term study of shoulder joints afflicted with and treated for calcific tendinitis[J].Clin Orthop,1961,20(20):61-72.

[2] Bosworth BM.Calcium deposits in the shoulder and subacromial bursitis-A survey of 12,122 shoulders[J].J Am Med Assoc,1941,116(116):2477-2482.

[3] Giuseppe P,Paolo P,Fabrizio C,et al.Arthroscopic treatment of calcifying tendonitis of the shoulder:clinical and ultrasonographic follow-up findings at two to five years[J].J Shoulder EIbow Surg,2004,13(5):503-508.

[4] Romain S,Heike L,Dieter K,et al.Arthroscopic treatment of chronically painful calcifying tendonitis of the supraspinatus tendon[J].Arthroscopy,2006,22(5):521-527.

[5] Rowe CR.Calcific tendinitis[J].Instr Course Lect，1985,34,196-198.

[6] Codman EA.The shoulder[M].Boston:Todd,1934:178-215.

[7] Uhthoff HK,Sarkar K.Calcifying tendinitis[J].Baillieres Clin Rheumatol,1989,3(3):567-581.

[8] 蔡第心，譚洪波，楊軍，等.肩袖鈣化性肌腱炎的病程研究分期及治療進(jìn)展[J/CD].中華肩肘外科電子雜志，2014,2(4)：248-250.

[9] Rochwerger A,Franceschi JP,Viton JM,et al.Surgical management of calcific tendinitis of the shoulder:an analysis of 26 cases[J].Clin Rheumatol,1999,18(4):313-316.

[10] Ellman H.Arthroscopic subacromial decompression:analysis of one-to three-year results[J].Arthroscopy,1987,3(3):173-181.

[11] Lam E,Bhatra D,Van Rooyen K,et al.Modern management of calcifyingtendinitis of the shoulder[J].Curr Orthop,2006(20):446-452.

[11] Balke M,Bielefeld R,Schmidt C,et al.Calcifying tendinitis of the shoulder:midterm results after arthroscopic treatment[J].Am J Sports Med,2012,40(3):657-661.

[12] Molé D,Kempf JF,Gleyze P,et al.[Results of endoscopic treatment of non-broken tendinopathies of the rotator cuff.2.Calcifications of the rotator cuff][J].Rev Chir Orthop,1993，79(7):532-541.

[13] Sirveaux F,Gosselin O,Roche O,et al.Postoperative results after arthroscopic treatment of rotator cuff calcifying tendonitis,with or without associated glenohumeral exploration[J].Rev Chir Orthop Reparatrice Appar Mot,2005,91(4):295-299.

[14] Tillander BM,Norlin RO.Change of calcifications after arthroscopic subacromial decompression[J].J Shoulder Elbow Surg,1998,7(3):213-217.

[15] Maier D,Jaeger M,Izadpanah K,et al.Rotator cuff preservation in arthroscopic treatment of calcific tendinitis[J].Arthroscopy,2013,29(5):824-831.

[16] Jacobs R,Debeer P.Calcifying tendinitis of the rotator cuff:functional outcome after arthroscopic treatment[J].Acta Orthop Belg,2006,72(3):276-281.

[17] Loew M,Daecke W,Kusnierczak D,et al.Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder[J].J Bone Joint Surg Br,1999,81(5):863-867.

(本文編輯：李靜)

陳建海,張一翀,張殿英，等.肩關(guān)節(jié)鈣化性肌腱炎的關(guān)節(jié)鏡治療及急慢性期療效比較[J/CD].中華肩肘外科電子雜志,2015,3(2):95-101.

Treatment of calcifying tendonitis of shoulder with arthroscopy and comparison of efficacy

ChenJianhai,ZhangYichong,ZhangDianying,FuZhongguo,YangMing,DangYu,JiangBaoguo.

DepartmentofTraumaandOrthopedics,PekingUniversityPeople′sHospital，PekingUniversityTrafficMedicineCenter,Beijing100044,China

JiangBaoguo,Email:jiangbaoguo@vip.sina.com

Background Calcifying tendonitis of rotator cuff is a common disease that causes pain.It frequently occurs in people at 30-50s,especially in women.The acute calcifying tendonitis is characterized by persistent severe pain of shoulder joint of unknown reason.In case of severe symptoms,emergency treatment is needed.Most patients with acute phase diseases have good efficacy for conservative treatment.However,patients who do not respond to conservative treatment or with symptoms unrelieved that severely influence work and life,surgery that removes the calcifying lesion under the arthroscopy is recognized as the effective treatment.Recently,with the development of arthroscopy,removal of calcium compounds under the arthroscopy has become a common surgery and leads to good efficacy.This study was performed to assess the efficacy of removal of calcified lesion under arthroscopy for calcifying tendonitis of rotator cuff in patients with acute and chronic phases of diseases,and to determine the difference in shoulder joint function between acute and chronic phases after surgery.Methods General data:Cases with calcifying tendonitis who

treatment from September 2009 to June 2014 were included in this study.The inclusion criteria included:(1) who had history of severe shoulder joint pain; (2) who did not respond to conservative therapy; (3) who received arthroscopy.The exclusion criteria included:(1) who had complicated injury of rotator cuff; (2) who received open surgery.28 cases who met inclusion criteria were enrolled.The patients were assigned to the acute group and the chronic group by the time from the acute onset to removal of calcified lesion under arthroscopy.The acute group received removal of calcified lesion within 3 months after the onset of shoulder pain.The chronic group received removal of calcified lesion 3 months after the onset of shoulder pain that limited range of motion.28 cases had different degrees of pain and limited range of motion in the affected shoulder joint.All patients received imaging examinations.The size,shape of the calcified lesion in the shoulder joint and the shape of the acromion were determined based on the radiograph.Plain radiograph of the shoulder indicated oval or bar-shaped high-density cloudy calcification shadow in the rotator cuff below the acromion or inside the slightly lateral mucosal bursa.There were 10 cases with acute diseases in which the patients aged 38-68 years with a mean age of 52.6 years.In 5 cases,the left shoulder was affected.In 5 cases,the right shoulder was affected.The symptom was acute pain in the last 3 months.They had no previous history of obvious pain limited range of motion.The patients had acupuncture-similar feeling,increased temperature on regional skin,markedly tenderness of the shoulder and limited range of motion that severely influenced daily life before surgery.The preoperative radiograph indicated high-density calcification shadow in rotator cuff below the acromion.There were 18 chronic cases ranged from 40-73 years with a mean age of 55.5 years.7 cases had left shoulders affected and 11 cases had right shoulders affected.All patients had a history of severe pain.The pain relieved after persistence for a certain time but did not disappear.The shoulder pain was sometimes slight and sometimes severe.The range of motion of the shoulder joint was substantially limited,which influenced daily life.Surgery method:All surgeries were performed by chief or senior physicians at the Peking University Peoples’ Hospital.The cases were subject to general anesthesia on beach chair position.The bony marks were made before surgery.The arthroscopy was inserted through posterior approach to examine the glenohumeral joint.Severe inflammatory synovial hyperplasia of congestion was often observed on the wall inside the joint capsule.Some patients with limited range of motion had contracture in the rotator interval and thickened middle glenohumeral ligament.The structure of rotator cuff remained complete.The synovial tissue in the articular cavity was removed.The rotator interval and middle glenohumeral ligament were released.A needle was used to puncture the supraspinatus tendon and infraspinatus tendon through the outer edge of acromion to position the location of calcified lesion.If the calcified lesion was detected with the needle,there was calcium compound on the needle tip.After positioning of calcified lesion,it was marked with a PDS suture placed through the needle.The arthroscopy located in the subacromial space often observed obvious hyperplasia and congestion in the synovial membrane under acromion.Sometimes calcium compound was observed on the synovial membrane.The synovial membrane under the acromion was removed using shaver.The bleeding was stopped using radiofrequency coblation.The structure of rotator cuff was clearly revealed.The locations of calcified lesion were marked using sutures.The tendons were dissected along the direction of tendon fibers using blade to expose the lesion.The calcified lesion was removed with shaver.The toothpaste shaped calcium substances were observed.After complete removal of calcified lesions,the tendon of rotator cuff was observed for defectiveness.For big calcified lesions that involved 50% depth of the tendon or footprint bone surface of rotator cuff revealed,a 4.5 mm suture anchor was used to repair the rotator cuff.9 cases received repair of the rotator cuff.The osteophyte was thoroughly removed if any under the acromion.8 cases received combined acromioplasty.Postoperative rehabilitation and assessment:The affected extremity was slinged in a shoulder immobilizer.The cold pack was appropriately used within 1 week after surgery.The passive shoulder joint motion was assisted with the normal hand.The range of motion increased gradually.1 week later,the active motion was started gradually.6 weeks later,the resistance exercise and extension treatment were applied to the shoulder joint.3 months after surgery,the range of motion returned to normal and daily living activities returned to normal.For patients with combined rotator cuff repair,active exercise should start 6 weeks after the surgery to avoid loosening or another tearing on the repaired site.Each patient was assessed for Constant score,simple shoulder test (SST) score,range of motion of the shoulder joint and VAS pain score before and after surgery.Statistical method:Paired data before and after surgery was analyzed with t test.SPSS 15.0 software was used for statistical analysis.P<0.05 indicated he statistical significance.Results 28 cases were included in the retrospective study.The patients were subject to follow-up ranged from 6-33 months (with a mean of 18.8 months).The regular follow-up radiograph after surgery showed removal of calcified shadow.All patients were assessed for Constant score,VAS pain score,range of motion of the shoulder joint and simple shoulder test (SST) score before and after surgery.For 10 cases with acute phase diseases,the mean scores of Constant scale were 51.36 before treatment and 88.16 after treatment,increased by an average of 36.80.The anteflexion and uplift angle increased by about 77.00°.The external rotation increased by about 18.50°.SST questionnaire:The mean number of answers “Yes” was 5.02 before treatment and 9.32 after treatment,increased by an average of about 4.30.The mean scores for VAS were 9.12 before treatment and 4.62 after treatment,decreased by average of about 4.50.For 18 cases with acute phase diseases,the mean Constant scores were 63.70 before treatment and 88.03 after treatment,increased by an average of about 24.33.The mean number of answers “Yes” was 6.33 before treatment and 9.66 after treatment,increased by an average of about 3.33.The mean scores for VAS were 7.30 before treatment and 4.19 after treatment,decreased by an average of about 3.11.In this study,28 cases with calcifying tendonitis underwent removal of calcified lesion under arthroscopy and presented different degrees of function improvement in shoulder joint.The patients with calcifying tendonitis in the acute group had significantly better Constant score,SST growth and anteflexion and uplift angle and pain relief than the patients in the chronic group (P<0.05).In this study,9 cases received repair of rotator cuff,including 2 cases in the acute group,accounting for 20% of patients with acute phase diseases,and 7 cases in the chronic group,accounting for 38.9% of patients with chronic phase diseases.Discussion Calcifying tendonitis of rotator cuff is a common disease that causes acute shoulder pain.When the symptom severely influences daily life and conservative therapy is not effective,early removal of calcified lesion under the arthroscopy is effective for calcifying tendonitis and leads to good prognosis.

Shoulder joint;Tendinopathy;Arthroscopy;Treatment

10.3877/cma.j.issn.2095-5790.2015.02.006

國(guó)家自然科學(xué)基金(31371210)；教育部創(chuàng)新團(tuán)隊(duì)項(xiàng)目(IRT1021)；衛(wèi)生公益性產(chǎn)業(yè)科研專(zhuān)項(xiàng)基金(201002014)

100044北京大學(xué)人民醫(yī)院創(chuàng)傷骨科 北京大學(xué)交通醫(yī)學(xué)中心

姜保國(guó)，Email:jiangbaoguo@vip.sina.com

2015-05-16)