改良切开修复巨大肩袖撕裂初步疗效分析

陈广辉 王洪伟 高锋 吴琼 杨海宝 李铭章

·论著·

改良切开修复巨大肩袖撕裂初步疗效分析

陈广辉 王洪伟 高锋 吴琼 杨海宝 李铭章

目的评价改良切开修复巨大肩袖撕裂的临床疗效。方法回顾性分析自2012年3月至2015年3月东莞东华医院收治的行改良切开修复巨大肩袖撕裂患者10例的病例资料，其中男6例，女4例；年龄47～65岁，平均56．6岁；肩袖撕裂左7例，右3例。采用视觉模拟评分法（visual analysis scale，VAS）、Constant评分、美国加州大学洛杉矶分校（University of California at Los Angeles，UCLA）肩关节功能评分评价早期临床疗效。结果所有患者均获随访，随访时间为6～24个月，平均16．5个月。无切口感染、神经损伤。1例肩袖再撕裂，因患者疼痛轻、耐受好，未行翻修手术。VAS、UCLA、Constant评分均有改善，UCLA评分优3例，良5例，差2例，优良率为80%；Constant评分优3例，良5例，差2例，优良率为80%。结论采用改良切开修复巨大肩袖撕裂损伤较小，术后康复快，早期效果良好。

切开修复；巨大肩袖撕裂

肩袖是由冈上肌、冈下肌、肩胛下肌和小圆肌组成，在肱骨头解剖颈处形成袖套状结构。由于承受应力大，肩袖易退变，因此肩袖撕裂在临床上较为常见。Gerber等［1］定义巨大肩袖撕裂为至少2根肌腱的完全断裂，这一定义被广泛接受。巨大肩袖撕裂治疗困难，效果差，虽然肩关节镜技术已较为成熟，但在广大基层医院并未普及，尤其对于巨大肩袖撕裂镜下修复难度更大。本院自2012年3月至2015年3月对10例巨大肩袖撕裂患者尝试行改良切开修复，现将初期临床疗效报道如下。

资料与方法

一、一般资料

2012年3月至2015年3月，本院选取10例巨大肩袖撕裂患者行改良切开修复，其中男6例，女4例；年龄47～65岁，平均56．6岁；肩袖撕裂左7例，右3例。患者临床资料见表1。

二、手术方法

气管插管全身麻醉后将患者置于沙滩椅位，妥善固定气管插管预防意外脱出，常规消毒铺巾、贴膜，标记肩峰、喙突等骨性标记。对于合并肩胛下肌损伤患者，先取三角肌－胸大肌间隙入路，结扎切断胸肩峰动脉三角肌支，显露肩胛下肌腱，往往可见其于小结节止点处部分或完全断裂，合并肱二头肌长头腱脱位或半脱位。本组1例患者（图1）合并骨性Bankart损伤，将1枚3．5mm锚钉置入肩盂撕脱骨折处，与关节囊缝合修复。于肱骨小结节处置入1枚5．0mm锚钉，复位肱二头肌长头腱，缝线一端穿过肩胛下肌腱断端，一端穿过横韧带，中立位打结修复肩胛下肌、横韧带，透视无异常后关闭切口。1例患者合并肩关节脱位，急诊已手法复位，2个月后手术时见关节囊盂唇复合体愈合良好。如无合并肩胛下肌损伤，直接进入下述步骤。

肩峰前外侧小切口显露，顺三角肌前中肌纤维交界进入，显露冈上肌腱，可见撕裂，断端回缩，判断撕裂构型。本组患者肩关节0°外展位检查修复张力均不大，无须松解。于肱骨大结节处置入2枚3．5mm锚钉，缝线穿过冈上肌腱撕裂边缘，肩关节0°外展位打结，检查修复牢固，透视锚钉位置无异常，关闭切口。所有患者均用美国Smith－Nephew公司的双固定螺钉修复。

三、术后处理

所有患者颈腕吊带制动，麻醉清醒后即刻行手腕部活动，3d内重点疼痛控制，常规使用头孢2代抗生素预防感染。3d后开始肩关节被动前屈、外展、外旋并牵伸关节囊，预防粘连，禁止主动活动，肩胛下肌损伤者禁止被动外旋。6周内逐渐达到前屈90°、外展60°、外旋30°（肩胛下肌损伤者例外）。6周后开始主动前屈、外展、内外旋活动，配合爬墙、拉橡皮筋等锻炼方式，肩胛下肌损伤者可开始主、被动外旋活动，目标为术后3个月达到或接近正常肩关节活动范围。术后3个月开始力量练习，如举杠铃、拉橡皮筋等，长期维持以巩固疗效，预防功能再次下降。康复期间使用冰敷以减轻疼痛，循序渐进，预防肩袖再撕裂。

四、疗效评定

采用视觉模拟评分法（visual analysis scale，VAS）、Constant评分［2］、美国加州大学洛杉矶分校（University of California at Los Angeles，UCLA）肩关节功能评分［3］进行疗效评估，由1名医师独立完成。VAS评分总分10分，0分：无痛；3分以下：有轻微的疼痛，患者能忍受；4～6分：患者疼痛并影响睡眠，尚能忍受；7～10分：患者有渐强烈的疼痛，疼痛难忍。Constant评分总分100分，90～100分为优，80～89分为良，70～79分为可，＜70分为差。UCLA肩关节功能评分总分35分，34～35分为优，29～33分为良，＜29分为差。

表1 10例患者一般资料

图1 患者，男，47岁，交通伤致右冈上肌腱、肩胛下肌腱撕裂合并骨性Bankart损伤，伤后13d行巨大肩袖撕裂及Bankart损伤修复术。图A术前X线片示肱骨头上移；图B术前轴位CT示肩盂前缘撕脱骨折；图C术前轴位MRI示肩胛下肌腱撕裂，肱二头肌长头腱脱位；图D术前冠状面MRI示冈上肌腱撕裂；图E术前前屈上举；图F术前体侧外旋；图G术前体侧内旋；图H改良切开修复手术切口；图I术后1个月X线片示锚钉位置良好；图J术后3个月冠状面MRI示冈上肌腱完整；图K术后3个月轴位MRI示肩胛下肌完整、肱二头肌长头腱无脱位；图L术后前屈上举；M术后体侧外旋；图N术后体侧内旋

结 果

所有患者均获随访，随访时间为6～24个月，平均16．5个月。无切口感染、神经损伤。1例肩袖再撕裂，因患者疼痛轻、耐受好，未行翻修手术。VAS、UCLA、Constant评分均有改善，UCLA、Constant评分优3例，良5例，差2例，其中1例为肩袖再撕裂，1例合并肩关节僵硬，优良率为80% ，见表2。

讨 论

一、巨大肩袖撕裂的治疗现状及难点

肩袖的作用是支持和稳定盂肱关节，维持肩关节腔的密闭功能，保持滑液对关节软骨的营养，预防继发性骨性关节炎。肩袖及喙肩弓下压肱骨头，协助肩关节活动时的瞬时稳定性。Bedi等［4］报道巨大肩袖撕裂发生率占所有肩袖撕裂的10%～40%。因急性创伤导致的巨大肩袖撕裂少见，通常是慢性撕裂且伴有肌腱回缩［5］。本组病例大部分与创伤有关，原因可能是部分急诊医师知识更新较少，将不少慢性巨大肩袖撕裂患者误诊为“肩周炎、肩部软组织挫伤”，患者未能进一步明确诊断。巨大肩袖撕裂修复后易出现肌腱回缩、肌肉萎缩和脂肪浸润，导致临床效果不满意［6］。目前治疗的主要手段有非手术治疗、开放修复、关节镜下修复、肌腱移位、反式肩关节置换［7］。

本组患者均采取切开解剖修复，年龄均≤65岁，部分患者仍在工作，对肩关节功能要求高，部分患者效果不佳。此年龄的巨大肩袖撕裂治疗极具挑战。Favard等［8］对一组296例年龄＜65岁患者作回顾性、多中心研究，治疗方式包括：解剖修复、姑息性部分修复、皮瓣或肩袖假体修复、反式肩关节置换，Constant评分（65．6±3．4）分和主动上举147．7°±32°明显提高，解剖修复组Constant评分较其他三组明显高。笔者认为，＜65岁巨大肩袖撕裂患者应尽量采用解剖修复。

二、巨大肩袖撕裂切开修复的疗效

随着关节镜技术不断发展，镜下肩袖修复逐渐成为主流。但巨大肩袖撕裂镜下修复手术复杂、难度大，切开修复仍有一定价值，尤其对于肩关节镜技术欠成熟的基层单位。不少学者报道切开修复效果满意。Zumstein等［9］报道了一组27例巨大肩袖撕裂切开修复患者，23例平均随访9．9年，评估其临床及肩袖结构完整性，指出巨大肩袖撕裂切开修复长期临床结果优异，患者满意率高。Hanusch等［10］采用小切口切开双排修复24例有症状的大型和巨大肩袖撕裂患者，21例（87．5%）患者对手术效果满意，修复后20例（83%）患者肩袖保持完整。本组患者均采用切开修复，初期疗效可。

表2 10例患者术前及末次随访时VAS，UCLA，Constant评分结果（分）

三、改良切开修复的优势

肩袖撕裂切开修复主要切口有前外侧小切口、Langer线切口、三角肌－胸大肌切口［11］。前外侧小切口显露冈上肌及冈下肌上部分充分，但难以显露肩胛下肌、小圆肌。Langer线切口显露后上肩袖充分，肩胛下肌显露欠佳，且需剥离三角肌肩峰止点。三角肌－胸大肌切口显露肩胛下肌及前上肩袖充分，可同时处理前盂唇关节囊损伤，但显露冈下肌不足。巨大肩袖撕裂往往联合冈上肌、冈下肌及肩胛下肌撕裂，本组患者1例合并Bankart损伤，单一切口难以完成手术。

为弥补单一切口不足，同时避免大切口导致的肌肉止点广泛剥离，笔者采用联合入路处理。三角肌－胸大肌切口处理肩胛下肌、肱二头肌长头腱损伤，如合并Bankart损伤可一并处理，前外侧小切口处理冈上肌及部分冈下肌损伤，显露充分，不剥离三角肌肩峰止点，损伤小，康复较快，值得提倡。

本组7例患者有肩胛下肌损伤。Wieser等［12］通过透视、MRI和电生理评估巨大肩袖撕裂的肩关节，结论是不管肩袖撕裂如何延伸，肩关节功能恢复最重要的预测因素是肩胛下肌下方止点的完整性。故修复肩胛下肌极为重要，充分的显露是解剖修复的基础。笔者采用三角肌－胸大肌入路，显露肩胛下肌满意，如合并Bankart损伤应先处理，然后处理肩胛下肌、肱二头肌长头腱损伤，修复肩胛下肌时肩关节外旋0°，以免出现外旋受限。

关于手术时机，笔者认为急性创伤性肩袖撕裂应尽早手术，以免后期出现肌腱断端挛缩、局部粘连、肌肉脂肪浸润，增加手术难度及并发症，使预后不良，与文献报道［7，13］的观点一致。对于慢性撕裂，术前的非手术治疗是必需的。

四、改良切开修复的局限性

由于肩峰阻挡，切开修复对肩袖撕裂的全面探查存在局限性，对撕裂构型判断可能存在偏差，可能遗漏部分撕裂，造成修复不足或术后再撕裂几率增加，影响疗效。故术中需结合术前MRI仔细评估肩袖撕裂构型，如能结合关节镜辅助镜检查则不致遗漏病变。本组1例出现肩袖再撕裂，可能与撕裂构型判断及修复张力过高有关，因患者疼痛轻、耐受好，未行翻修手术。Kim等［14］总结61例关节镜下肩袖修复患者，指出如术后3个月内肌腱达到足够的机械及生物学愈合且完整，3个月后再撕裂者少。提示应追求足够强度的解剖修复，以利于肌腱的完整愈合，减少再撕裂几率。由于采用联合切口，需确保切口之间皮肤宽度＞7cm，以免皮肤坏死。

由于病例数局限，积累经验有限，待解决的问题仍较复杂，特别是肩部的生物力学和腱性组织生物学修复和病理学的基础研究，合并肱二头肌长头腱损伤的处理，且临床疗效需长期随访进一步判断。

综上所述，改良切开修复巨大肩袖撕裂能有效显露并处理病变，无需剥离三角肌前缘止点，节省手术时间，术后康复快，尤其对于肩关节镜技术经验不足的单位和医师具有推广价值。

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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）

（本文编辑：胡桂英；英文编辑：陈建海、张晓萌、张立佳）

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

东莞市医疗卫生基金项目（201610515000302）

523110 东莞东华医院骨一科

陈广辉，Email：sumscool＠aliyun．com

陈广辉，王洪伟，高锋，等．改良切开修复巨大肩袖撕裂初步疗效分析 ［J/CD］．中华肩肘外科电子杂志，2017，5（1）：54－60．