陳廣輝 王洪偉 高鋒 吳瓊 楊海寶 李銘章

·論著·

改良切開修復巨大肩袖撕裂初步療效分析

陳廣輝 王洪偉 高鋒 吳瓊 楊海寶 李銘章

目的評價改良切開修復巨大肩袖撕裂的臨床療效。方法回顧性分析自2012年3月至2015年3月東莞東華醫(yī)院收治的行改良切開修復巨大肩袖撕裂患者10例的病例資料，其中男6例，女4例；年齡47～65歲，平均56．6歲；肩袖撕裂左7例，右3例。采用視覺模擬評分法（visual analysis scale，VAS）、Constant評分、美國加州大學洛杉磯分校（University of California at Los Angeles，UCLA）肩關節(jié)功能評分評價早期臨床療效。結果所有患者均獲隨訪，隨訪時間為6～24個月，平均16．5個月。無切口感染、神經損傷。1例肩袖再撕裂，因患者疼痛輕、耐受好，未行翻修手術。VAS、UCLA、Constant評分均有改善，UCLA評分優(yōu)3例，良5例，差2例，優(yōu)良率為80%；Constant評分優(yōu)3例，良5例，差2例，優(yōu)良率為80%。結論采用改良切開修復巨大肩袖撕裂損傷較小，術后康復快，早期效果良好。

切開修復；巨大肩袖撕裂

肩袖是由岡上肌、岡下肌、肩胛下肌和小圓肌組成，在肱骨頭解剖頸處形成袖套狀結構。由于承受應力大，肩袖易退變，因此肩袖撕裂在臨床上較為常見。Gerber等［1］定義巨大肩袖撕裂為至少2根肌腱的完全斷裂，這一定義被廣泛接受。巨大肩袖撕裂治療困難，效果差，雖然肩關節(jié)鏡技術已較為成熟，但在廣大基層醫(yī)院并未普及，尤其對于巨大肩袖撕裂鏡下修復難度更大。本院自2012年3月至2015年3月對10例巨大肩袖撕裂患者嘗試行改良切開修復，現將初期臨床療效報道如下。

資料與方法

一、一般資料

2012年3月至2015年3月，本院選取10例巨大肩袖撕裂患者行改良切開修復，其中男6例，女4例；年齡47～65歲，平均56．6歲；肩袖撕裂左7例，右3例?；颊吲R床資料見表1。

二、手術方法

氣管插管全身麻醉后將患者置于沙灘椅位，妥善固定氣管插管預防意外脫出，常規(guī)消毒鋪巾、貼膜，標記肩峰、喙突等骨性標記。對于合并肩胛下肌損傷患者，先取三角?。卮蠹￠g隙入路，結扎切斷胸肩峰動脈三角肌支，顯露肩胛下肌腱，往往可見其于小結節(jié)止點處部分或完全斷裂，合并肱二頭肌長頭腱脫位或半脫位。本組1例患者（圖1）合并骨性Bankart損傷，將1枚3．5mm錨釘置入肩盂撕脫骨折處，與關節(jié)囊縫合修復。于肱骨小結節(jié)處置入1枚5．0mm錨釘，復位肱二頭肌長頭腱，縫線一端穿過肩胛下肌腱斷端，一端穿過橫韌帶，中立位打結修復肩胛下肌、橫韌帶，透視無異常后關閉切口。1例患者合并肩關節(jié)脫位，急診已手法復位，2個月后手術時見關節(jié)囊盂唇復合體愈合良好。如無合并肩胛下肌損傷，直接進入下述步驟。

肩峰前外側小切口顯露，順三角肌前中肌纖維交界進入，顯露岡上肌腱，可見撕裂，斷端回縮，判斷撕裂構型。本組患者肩關節(jié)0°外展位檢查修復張力均不大，無須松解。于肱骨大結節(jié)處置入2枚3．5mm錨釘，縫線穿過岡上肌腱撕裂邊緣，肩關節(jié)0°外展位打結，檢查修復牢固，透視錨釘位置無異常，關閉切口。所有患者均用美國Smith－Nephew公司的雙固定螺釘修復。

三、術后處理

所有患者頸腕吊帶制動，麻醉清醒后即刻行手腕部活動，3d內重點疼痛控制，常規(guī)使用頭孢2代抗生素預防感染。3d后開始肩關節(jié)被動前屈、外展、外旋并牽伸關節(jié)囊，預防粘連，禁止主動活動，肩胛下肌損傷者禁止被動外旋。6周內逐漸達到前屈90°、外展60°、外旋30°（肩胛下肌損傷者例外）。6周后開始主動前屈、外展、內外旋活動，配合爬墻、拉橡皮筋等鍛煉方式，肩胛下肌損傷者可開始主、被動外旋活動，目標為術后3個月達到或接近正常肩關節(jié)活動范圍。術后3個月開始力量練習，如舉杠鈴、拉橡皮筋等，長期維持以鞏固療效，預防功能再次下降?？祻推陂g使用冰敷以減輕疼痛，循序漸進，預防肩袖再撕裂。

四、療效評定

采用視覺模擬評分法（visual analysis scale，VAS）、Constant評分［2］、美國加州大學洛杉磯分校（University of California at Los Angeles，UCLA）肩關節(jié)功能評分［3］進行療效評估，由1名醫(yī)師獨立完成。VAS評分總分10分，0分：無痛；3分以下：有輕微的疼痛，患者能忍受；4～6分：患者疼痛并影響睡眠，尚能忍受；7～10分：患者有漸強烈的疼痛，疼痛難忍。Constant評分總分100分，90～100分為優(yōu)，80～89分為良，70～79分為可，＜70分為差。UCLA肩關節(jié)功能評分總分35分，34～35分為優(yōu)，29～33分為良，＜29分為差。

表1 10例患者一般資料

圖1 患者，男，47歲，交通傷致右岡上肌腱、肩胛下肌腱撕裂合并骨性Bankart損傷，傷后13d行巨大肩袖撕裂及Bankart損傷修復術。圖A術前X線片示肱骨頭上移；圖B術前軸位CT示肩盂前緣撕脫骨折；圖C術前軸位MRI示肩胛下肌腱撕裂，肱二頭肌長頭腱脫位；圖D術前冠狀面MRI示岡上肌腱撕裂；圖E術前前屈上舉；圖F術前體側外旋；圖G術前體側內旋；圖H改良切開修復手術切口；圖I術后1個月X線片示錨釘位置良好；圖J術后3個月冠狀面MRI示岡上肌腱完整；圖K術后3個月軸位MRI示肩胛下肌完整、肱二頭肌長頭腱無脫位；圖L術后前屈上舉；M術后體側外旋；圖N術后體側內旋

結 果

所有患者均獲隨訪，隨訪時間為6～24個月，平均16．5個月。無切口感染、神經損傷。1例肩袖再撕裂，因患者疼痛輕、耐受好，未行翻修手術。VAS、UCLA、Constant評分均有改善，UCLA、Constant評分優(yōu)3例，良5例，差2例，其中1例為肩袖再撕裂，1例合并肩關節(jié)僵硬，優(yōu)良率為80% ，見表2。

討 論

一、巨大肩袖撕裂的治療現狀及難點

肩袖的作用是支持和穩(wěn)定盂肱關節(jié)，維持肩關節(jié)腔的密閉功能，保持滑液對關節(jié)軟骨的營養(yǎng)，預防繼發(fā)性骨性關節(jié)炎。肩袖及喙肩弓下壓肱骨頭，協助肩關節(jié)活動時的瞬時穩(wěn)定性。Bedi等［4］報道巨大肩袖撕裂發(fā)生率占所有肩袖撕裂的10%～40%。因急性創(chuàng)傷導致的巨大肩袖撕裂少見，通常是慢性撕裂且伴有肌腱回縮［5］。本組病例大部分與創(chuàng)傷有關，原因可能是部分急診醫(yī)師知識更新較少，將不少慢性巨大肩袖撕裂患者誤診為“肩周炎、肩部軟組織挫傷”，患者未能進一步明確診斷。巨大肩袖撕裂修復后易出現肌腱回縮、肌肉萎縮和脂肪浸潤，導致臨床效果不滿意［6］。目前治療的主要手段有非手術治療、開放修復、關節(jié)鏡下修復、肌腱移位、反式肩關節(jié)置換［7］。

本組患者均采取切開解剖修復，年齡均≤65歲，部分患者仍在工作，對肩關節(jié)功能要求高，部分患者效果不佳。此年齡的巨大肩袖撕裂治療極具挑戰(zhàn)。Favard等［8］對一組296例年齡＜65歲患者作回顧性、多中心研究，治療方式包括：解剖修復、姑息性部分修復、皮瓣或肩袖假體修復、反式肩關節(jié)置換，Constant評分（65．6±3．4）分和主動上舉147．7°±32°明顯提高，解剖修復組Constant評分較其他三組明顯高。筆者認為，＜65歲巨大肩袖撕裂患者應盡量采用解剖修復。

二、巨大肩袖撕裂切開修復的療效

隨著關節(jié)鏡技術不斷發(fā)展，鏡下肩袖修復逐漸成為主流。但巨大肩袖撕裂鏡下修復手術復雜、難度大，切開修復仍有一定價值，尤其對于肩關節(jié)鏡技術欠成熟的基層單位。不少學者報道切開修復效果滿意。Zumstein等［9］報道了一組27例巨大肩袖撕裂切開修復患者，23例平均隨訪9．9年，評估其臨床及肩袖結構完整性，指出巨大肩袖撕裂切開修復長期臨床結果優(yōu)異，患者滿意率高。Hanusch等［10］采用小切口切開雙排修復24例有癥狀的大型和巨大肩袖撕裂患者，21例（87．5%）患者對手術效果滿意，修復后20例（83%）患者肩袖保持完整。本組患者均采用切開修復，初期療效可。

表2 10例患者術前及末次隨訪時VAS，UCLA，Constant評分結果（分）

三、改良切開修復的優(yōu)勢

肩袖撕裂切開修復主要切口有前外側小切口、Langer線切口、三角?。卮蠹∏锌冢?1］。前外側小切口顯露岡上肌及岡下肌上部分充分，但難以顯露肩胛下肌、小圓肌。Langer線切口顯露后上肩袖充分，肩胛下肌顯露欠佳，且需剝離三角肌肩峰止點。三角?。卮蠹∏锌陲@露肩胛下肌及前上肩袖充分，可同時處理前盂唇關節(jié)囊損傷，但顯露岡下肌不足。巨大肩袖撕裂往往聯合岡上肌、岡下肌及肩胛下肌撕裂，本組患者1例合并Bankart損傷，單一切口難以完成手術。

為彌補單一切口不足，同時避免大切口導致的肌肉止點廣泛剝離，筆者采用聯合入路處理。三角?。卮蠹∏锌谔幚砑珉蜗录?、肱二頭肌長頭腱損傷，如合并Bankart損傷可一并處理，前外側小切口處理岡上肌及部分岡下肌損傷，顯露充分，不剝離三角肌肩峰止點，損傷小，康復較快，值得提倡。

本組7例患者有肩胛下肌損傷。Wieser等［12］通過透視、MRI和電生理評估巨大肩袖撕裂的肩關節(jié)，結論是不管肩袖撕裂如何延伸，肩關節(jié)功能恢復最重要的預測因素是肩胛下肌下方止點的完整性。故修復肩胛下肌極為重要，充分的顯露是解剖修復的基礎。筆者采用三角?。卮蠹∪肼?，顯露肩胛下肌滿意，如合并Bankart損傷應先處理，然后處理肩胛下肌、肱二頭肌長頭腱損傷，修復肩胛下肌時肩關節(jié)外旋0°，以免出現外旋受限。

關于手術時機，筆者認為急性創(chuàng)傷性肩袖撕裂應盡早手術，以免后期出現肌腱斷端攣縮、局部粘連、肌肉脂肪浸潤，增加手術難度及并發(fā)癥，使預后不良，與文獻報道［7，13］的觀點一致。對于慢性撕裂，術前的非手術治療是必需的。

四、改良切開修復的局限性

由于肩峰阻擋，切開修復對肩袖撕裂的全面探查存在局限性，對撕裂構型判斷可能存在偏差，可能遺漏部分撕裂，造成修復不足或術后再撕裂幾率增加，影響療效。故術中需結合術前MRI仔細評估肩袖撕裂構型，如能結合關節(jié)鏡輔助鏡檢查則不致遺漏病變。本組1例出現肩袖再撕裂，可能與撕裂構型判斷及修復張力過高有關，因患者疼痛輕、耐受好，未行翻修手術。Kim等［14］總結61例關節(jié)鏡下肩袖修復患者，指出如術后3個月內肌腱達到足夠的機械及生物學愈合且完整，3個月后再撕裂者少。提示應追求足夠強度的解剖修復，以利于肌腱的完整愈合，減少再撕裂幾率。由于采用聯合切口，需確保切口之間皮膚寬度＞7cm，以免皮膚壞死。

由于病例數局限，積累經驗有限，待解決的問題仍較復雜，特別是肩部的生物力學和腱性組織生物學修復和病理學的基礎研究，合并肱二頭肌長頭腱損傷的處理，且臨床療效需長期隨訪進一步判斷。

綜上所述，改良切開修復巨大肩袖撕裂能有效顯露并處理病變，無需剝離三角肌前緣止點，節(jié)省手術時間，術后康復快，尤其對于肩關節(jié)鏡技術經驗不足的單位和醫(yī)師具有推廣價值。

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Analysis of early therapeutic effect of modified open repair of massive rotator cuff tear

Chen Guanghui，Wang Hongwei，Gao Feng，Wu Qiong，Yang Haibao，Li Mingzhang．Department of Orthopaedic，Dongguan Donghua Hospital，Dongguan 523110，China

Chen Guanghui，Email：sumscool＠aliyun．com

BackgroundThe rotator cuff is composed of supraspinatus，infraspinatus，subscapularis and teres minor，forming a sleeve structure around the anatomical neck of humerus．Due to the large bearing stress，the rotator cuff is easy to degenerate and its tear is common in clinical practice．Gerber，etc．defines massive rotator cuff tear as complete rupture of at least 2tendons，which is widely accepted．The treatment of massive rotator cuff tear is difficult with poor outcomes．Although the shoulder arthroscopic technology has been mature，it is not popularized in the extensive primary hospitals，especially for the greater difficulty of arthroscopic repair．Methods（1）General information：From March 2012to March 2015，10patients of massive rotator cuff tear were treated with modified open repair in our hospital，including 6males and 4females，aged from 47to 65years with an average of 56．6years；7cases were in the left and 3cases were in the right．（2）Operative methods：Under successful general anesthesia with endotracheal intubation，the patient was placed in beach chair position and the tracheal tube was properly fixed to avoid accidental slipping out．The bone landmarks such as acromion，coracoid process，etc．were marked after conventional disinfection and draping．As for patients combined with subscapularis injury，the subscapularis tendon was exposed after the ligation of the deltoid branch of thoracoacromial artery through the deltopectoral approach，and the partial or complete laceration was usually seen at the attachment point of small tuberosity with subluxation or dislocation of the long head of biceps tendon．One patient in this group was found to have Bankart injury and treated with a 3．5mm suture anchor placed in the glenoid avulsion fracture to repair the joint capsule．After the reduction of the long head of biceps tendon，a 5．0mm suture anchor was placed in lesser tuberosity with one suture penetrated through the end of subscapularis tendon andthe other through transverse ligament．After the sutures were fastened with knots at the neutral position of shoulder joint，both the subscapularis tendon and the transverse tendon were repaired．One patient with shoulder joint dislocation had emergency manipulative reduction and

good recovery of Bankart lesion 2months later．Without subscapularis injury，the following procedures were carried out directly．Through the small incision of anterolateral acromion and along the anterior and middle bundles of deltoid，the supraspinatus tendon was exposed to find the laceration and its retracted end and decide the tearing configuration．The shoulder joint was examined at 0°of shoulder abduction and the surgical release was unnecessary as the tension after repair was not large．Two 3．5mm anchors were inserted into the greater tuberosity with sutures penetrated through the tearing rim of supraspinatus tendon．The knots were fastened at 0°of shoulder abduction and the repair was examined to be firm．The incision was closed as no malposition of anchors was found under fluoroscopy．（3）Postoperative management：The affected arm was in a sling for limitation of activities and wrist activities were encouraged immediately after anesthesia．The emphasis within 3days was focused on pain control and the 2nd generation of cephalosporin was given regularly for postoperative infection prevention．The passive activities of forward flexion，abduction and external rotation were allowed 3days later to distract the joint capsule and prevent adhesion，but not for the patient with subscapular injury．The active movements were also forbidden．The range of motion reached gradually at 90°of forward flexion，60°of abduction and 30°external rotation within 6weeks（excluding patients with subscapular injury）．The active forward flexion，abduction and internal and external rotation was allowed 6weeks later，and accompanied by climbing action and pulling rubber band，the active and passive exercises were permitted to carry out in patients with subscapularis injuries．The goal was to reach the normal range of shoulder motion at 3months after the operation．3months after operation，the strength training，such as raising barbell，pulling rubber band，etc．were carried out with longterm maintenance to consolidate the curative effect and prevention the function from decreasing again．Ice compress in the rehabilitation facilitated pain relief and the principle of gradual improvement should be followed to avoid the palindromia rotator cuff tear．（4）Assessment of curative effect：The curative effect assessment of shoulder joint was completed by one clinician independently with visual analysis scale（VAS），Constant－Murley score and University of California at Los Angeles（UCLA）score．The total score of VAS was 10points with 0point for pain free，less than 3points for slight and tolerable pain，4－6points for mild pain which may affect the sleep but is still endurable and 7－10points for severe and insufferable pain．The total score of Constant－Murley was 100points with 90－100points in excellent，80－89points in good，70－79points in normal and less than 70points in poor．The total score of UCLA was 35points with 34－35points in excellent，29－33points in good and less than 29points in poor．Results All patients were followed up for 6to 24months with an average of 16．5months．No incision infection or nerve injury was found．One patient had the recurrence of rotator cuff tear，but had no revision surgery due to the slight pain and his good tolerance．VAS score，UCLA score and Constant－Murley score were all improved．According to UCLA score and Constant－Murley score，there were 3excellent cases，5good cases and 2poor cases，including 1case of recurrence and 1case of shoulder joint stiffness．The excellent and good rate was 80%．Conclusions Due to limited cases and experience，the remained problem is still complex，especially the basic study of shoulder biomechanics，biological repair of tendon tissue and pathology，and the treatment of long head injury of biceps tendon．The clinical effect requires long－term follow－ups and further analysis．In summery，the massive rotator cuff tear can be easily exposed and treated through modified open repair without stringing the anterior attachment of deltoid，which saves the operation time，accelerates the postoperative rehabilitation and particularly has the promotion value in hospitals and clinicians with insufficient shoulder arthroscopic experience．

Open repair；Massive rotator cuff tear

2016－03－17）

（本文編輯：胡桂英；英文編輯：陳建海、張曉萌、張立佳）

10．3877/cma．j．issn．2095－5790．2017．01．009

東莞市醫(yī)療衛(wèi)生基金項目（201610515000302）

523110 東莞東華醫(yī)院骨一科

陳廣輝，Email：sumscool＠aliyun．com

陳廣輝，王洪偉，高鋒，等．改良切開修復巨大肩袖撕裂初步療效分析 ［J/CD］．中華肩肘外科電子雜志，2017，5（1）：54－60．