肱二头肌长头腱切断结节间沟下关节外固定治疗老年SLAP损伤患者的疗效分析

赵加松 汪国友 曾胜强 暴丁溯 沈骅睿 扶世杰

肱二头肌长头腱切断结节间沟下关节外固定治疗老年SLAP损伤患者的疗效分析

赵加松 汪国友 曾胜强 暴丁溯 沈骅睿 扶世杰

目的分析肱二头肌长头腱切断结节间沟下固定治疗老年上盂唇前后部（superior labral anterior and posterior，SLAP）损伤患者的临床疗效。方法回顾性分析西南医科大学附属中医医院2014年1月至2015年1月行肩关节镜治疗的35例Ⅱ、Ⅳ型老年SLAP损伤患者的临床资料，其中肱二头肌长头腱切断结节间沟下关节外固定17例（A组），男9例、女8例，年龄51～68岁，平均58.6岁，左侧7例、右侧10例；肱二头肌长头腱切断关节内固定18例（B组）,男11例、女7例，年龄51～68岁，平均59.8岁，左侧8例、右侧10例。术后循序渐进行功能康复锻炼，采用美国肩肘外科协会评分（America shoulder and elbow surgeons'form, ASES）和视觉模拟评分（visual analog scale, VAS）评价治疗效果。结果35例患者均获随访，随访时间为1年。术后的ASES评分和 VAS评分较术前明显改善，差异均有统计学意义（P ＜0.05），两组患者手术时间差异无统计学意义（P＞0.05），所有患者均未发生神经损伤、伤口感染等并发症。结论肱二头肌长头腱切断结节间沟下关节外固定治疗老年SLAP损伤患者的临床疗效确切，是一种值得推广的治疗方法。

关节镜； 肱二头肌长头腱； 结节间沟； 老年； SLAP损伤

随着人们生活质量的不断提高和全民体育运动的普及，运动损伤人群数量呈上升趋势，上盂唇前后部（superior labral anterior and posterior，SLAP）损伤患者也日益增多。随着肩关节镜微创技术的不断发展及对肩关节疾病诊断水平的日益提高，人们逐渐认识到SLAP损伤是导致临床上肩部功能障碍的重要因素。SLAP损伤多发生于青年人或特种运动员，其主要症状是疼痛，投掷运动过头动作时加重，有时出现绞锁、弹响及不稳定机械症状，不稳定的主诉少见。引起SLAP损伤的原因包括肱二头肌腱受到外力影响，盂肱关节不稳定等［1］。老年人发病率较低，多见于退变原因，年龄是影响SLAP损伤修复术后临床效果的重要因素，老年患者仍然可取得良好的手术疗效，然而需要术前仔细评估患者需求、手术风险及术后应施行有效的康复理疗。肱二头肌长头肌腱固定术或切断术是SLAP损伤修复的一种选择［2］。西南医科大学附属中医医院骨关节科收治的Snyder分型中Ⅱ、Ⅳ型老年SLAP损伤患者35例，疗效确切，现报道如下。

资料与方法

一、一般资料

回顾性分析本院2014年1月至2015年1月行肩关节镜治疗的35例Ⅱ、Ⅳ型老年SLAP损伤患者的临床资料，其中肱二头肌长头腱结节间沟下关节外钻孔固定17例（A组），男9例、女8例，年龄51～68岁，平均58.6岁，左侧7例、右侧10例；肱二头肌长头腱切断关节内固定18例（B组），男11例、女7例，年龄51～68岁，平均59.8岁，左侧8例、右侧10例。术前通过病史询问、查体和MRI检查确定肩关节盂唇损伤的诊断。术前完善相关检查，充分术前准备，无绝对手术及麻醉禁忌。

二、纳入标准

（1）年龄＞50岁；（2）患肩出现弹响、机械性绞锁等症状，持续3～6个月且康复锻炼无效者；（3）正规保守治疗6～8个月无效者；（4）伴肩关节不稳者。

三、排除标准

（1）肩关节习惯性脱位患者；（2）肩峰下滑囊炎引起的肩峰下压痛患者；（3）肩关节有开放性伤口或者感染的患者；（4）合并有其他部位的损伤，暂时无法行手术治疗的患者；（5）患有其他慢性疾病、传染病等不宜行手术治疗的患者。

四、手术方法

全身麻醉后，术中取沙滩椅位，常规消毒铺巾，铺防水中单，取肩关节前外侧和后、前侧手术入路进行关节镜检查。术中首先对盂肱关节内结构进行探查，明确盂唇损伤类型为Ⅱ、Ⅳ型SLAP损伤，同时探查是否有其他病变，如滑膜增生、关节内游离体、关节囊松弛及肩盂骨质缺损等，视情况行相应处理。如可先处理增生滑膜、取出游离体等，用刨削刀或磨钻处理创面或去骨皮质，得到出血或新鲜的骨创面以利于盂唇的重新附着后的愈合。根据术中盂唇清创情况，于SLAP损伤处行或不行锚钉固定修复，再于关节镜下切断肱二头肌长头腱，予以关节内固定或小切口关节外结节间沟处钻孔固定（图1～5），大量生理盐水冲洗，防止血浆引流管，缝合切口，术毕。手术前后常规拍摄X线片（图6、7）。

五、术后处理

术后予以抗感染、止痛及间断冰敷处理，肩部予以肩关节支具外展制动，术后第2天拔出血浆引流管。遵循循序渐进过程，术后2周内行握拳、主被动屈肘活动，逐渐行患肩的被动前屈、外展及背伸活动，3周后逐渐行患肩无痛性主动前屈、外展及背伸活动，6周后开始行患肩无痛全范围活动。术后3个月进行肌力训练，术后6个月恢复原运动水平。

六、疗效评定标准

术前、术后根据美国肩肘外科医师评分（America shoulder and elbow surgeons'form，ASES）［3］及 视觉模拟评分（visual analog scale，VAS）评估患者肩关节功能和疼痛情况。ASES评分满分为100分，其中疼痛占36%，稳定占36%，功能占28%，分数越高代表肩关节功能越好。VAS评分满分为10分，0分:无痛；3分以下:有轻微的疼痛，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，影响食欲，影响睡眠。

七、统计学分析

应用SPSS17.0统计软件进行数据分析，计量资料以 x-±s表示，采用t检验，P ＜0.05为差异有统计学意义。

结 果

所有患者均获随访，随访时间为1年。术后的ASES评分和VAS评分较术前明显改善（表1），术前和术后肩关节功能ASES评分及VAS评分，差异均有统计学意义（P ＜0.05），两组患者手术时间差异无统计学意义（P＞0.05），所有患者均未发生神经损伤、伤口感染等并发症。

图1 关节镜下切断肱二头肌长头腱后，关节外结节间沟下拉出肱二头肌长头腱

图2 编制缝合肱二头肌长头腱，于结节间沟下钻孔

图3 引线穿过钻孔后加强缝合固定

图4 结节间沟下钻孔引线示意图

图5 加强缝合固定示意图

图6 术前X线片

图7 术后X线片

表1 两组患者手术前后ASES 、VAS评分及手术时间比较（±s）

表1 两组患者手术前后ASES 、VAS评分及手术时间比较（±s）

注：与术前相比，aP＜0.05；AESE为美国肩肘外科协会评分；VAS为视觉模拟评分

组别 例数 AESE评分（分） VAS评分（分） 手术时间（min）术前 术后 术前 术后A 组 17 45.8±7.2 86.5±5.4a 5.3±1.3 3.8±1.5 97.0±18.7 B 组 18 48.4±9.1 86.4±6.0 5.4±1.5 3.1±1.2a 96.1±18.5 t值 25.27 17.67 9.62 11.37 -5.12 P值 ＜0.001 ＜0.001 ＜0.001 ＜0.001 0.62

讨 论

SLAP损伤的主要症状是疼痛，投掷运动过头动作时加重，有时出现绞锁、弹响及不稳定机械症状，不稳定的主诉少见。随着人们生活水平的提高，老年SLAP损伤患者日益增多。在川南地区患病率较高，其受伤机制包括高处坠落或直接打击时；损伤时上肢处于外展前屈时；上肢牵引时；反复过度过头运动时，如羽毛球、游泳、篮球、投掷运动等。一些急性损伤也可造成SLAP损伤，例如，对上肢突然牵拉或打击而使肘关节从屈曲位强力伸展可造成急性SLAP损伤。另外，肩关节外展及轻度前屈位、肘关节伸直时突然摔倒着地，肱骨头向上方直接撞击和挤压盂唇也可造成SLAP损伤。1990年Waldherr等［3］和 Snyder等［4］将 SLAP 损伤分为四种类型，I型：盂唇上部外观呈磨损和退行性变；Ⅱ型：盂唇上部自其止点分离，沿着二头肌腱离开盂颈下方（盂唇复合体不稳定）；Ⅲ型：盂唇上部有桶柄状裂，二头肌腱完整；Ⅳ型：盂唇上部有桶柄状裂并延伸到二头肌腱内形成不同程度的劈裂。

对于SLAP损伤的诊断较为困难，有患者自诉肩关节活动或处于某些体位时（多为外展外旋位）疼痛，或伴随关节内的交锁、弹响，或不能完成某些动作，如投掷时的“上肢沉坠感”等。但总的来说，病史对盂唇损伤的诊断是非特异性的。除此之外，肩关节的体格检查对盂唇损伤的诊断也非常重要。回旋挤压试验和O'Brien试验阳性对于SLAP损伤的诊断具有很高的敏感性。对盂唇损伤导致的肩关节不稳，在全身麻醉下可行多方向抽屈试验并与健侧对比，其特异性和敏感性比较高。MRI检查对于肩关节软组织损伤的诊断十分有用，特别是肩袖、肱二头肌腱及周围软组织，但对盂唇和关节囊进行充分评估常感困难。因此需要MR关节造影术，对盂唇损伤的敏感度为89%，特异度为91%，精确度为90%［5］。王玉理等［6］回顾性收集35例SLAP损伤患者已行肩关节MR造影和关节镜检查，由2名医师观察分析，通过对照比较，评价肩关节MR造影的灵敏度、特异度和准确度分别是94%、96%和90%。在病程较长的老年肩痛的患者中，当症状与常见的肩痛病因不一致时，要考虑盂唇损伤，大多盂唇损伤仅能通过肩关节镜明确诊断。肩关节镜检查才是诊断SLAP损伤的“金标准”［7］。

目前，根据患者的年龄、活动水平及残余肱二头肌条件的不同，SLAP损伤的治疗方法也有所不同［8］，该损伤以Ⅱ型最常见［9］，随着关节镜技术的发展，针对损伤盂唇缝合与不缝合存在争议。陈广等［10］回顾性分析24例SLAP损伤患者，比较肩关节镜下带线锚钉缝合修复上盂唇与单纯清创治疗Ⅱ型SLAP损伤的疗效差异，结果表明，肩关节镜下带线锚钉缝合修复上盂唇较单纯清创治疗Ⅱ型SLAP损伤患者具有更好的临床疗效。本组病例中，选取Ⅱ、Ⅳ型SLAP损伤，关节镜下探查除SLAP损伤外，是否有其他病变，如滑膜增生、关节内游离体、关节囊松弛及肩盂骨质缺损等，视情况行相应处理。用刨削刀或磨钻处理创面或去骨皮质，得到出血或新鲜的骨创面以利于盂唇的重新附着后的愈合。根据术中盂唇清创情况，于SLAP损伤处行或不行锚钉固定修复，再于结节间沟下切断肱二头肌长头腱，予以钻孔固定，关节外切断肱二头肌腱较关节内切断减少了术后关节内的疼痛刺激因素。本组病例术后1年随访ASES评分和VAS评分较术前明显改善，差异均有统计学意义（P ＜0.05）。在本组病例中17例采用肱二头肌长头腱切断结节间沟下关节外固定，18例采用肱二头肌长头腱切断关节内固定，手术时间差异无统计学意义（P＞0.05），两种固定方式疼痛评分差异有统计学意义（P ＜0.05），说明肱二头肌长头腱关节内固定是术后关节内疼痛的刺激因素，钻孔固定费用相对较低，腱骨愈合相对较好，长期疗效确切。

总之，关节镜及肱二头肌长头腱切断结节间沟下关节外固定治疗老年SLAP损伤的临床疗效确切、手术创伤小、并发症少、可早期行功能锻炼，功能恢复快，是一种值得推广的微创治疗方法。然而，相对膝关节镜而言，肩关节镜操作技术难度高，学习曲线长，需要具备熟练的关节镜操作技术和经验较为丰富的关节运动损伤专业医师进行手术，才可取得理想的手术效果。

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Fu Shijie, Email: fu_fsj@sina.com

Therapeutic effect analysis of long head of biceps brachii tendectomy and intertubercular sulcus extraarticular tenodesis for treatment of senile SLAP injury

Zhao Jiasong, Wang Guoyou, Zeng Shengqiang,Bao Dingsu, Shen Huarui, Fu Shijie. Department of Bone and Joint, Southwest Medical University Affiliated Hospital of Traditional Chinese Medicine, Luzhou 646000 ,China

BackgroundWith the continuous improvement of people's life quality and the popularity of national sport, the number of people with athletic injury such as superior labral anterior and posterior （SLAP） lesion is on the rise. With the continuous development of minimally invasive shoulder arthroscopic technique and the increasing diagnostic level of shoulder joint disease, it is gradually realized that the SLAP lesion is an important factor which leads to shoulder dysfunction in clinic. The SLAP injury usually occurs in young people or special athletes. Pain is the main symptom, which increases during overhead throwing. Symptoms including interlocking, snapping and instability accompany sometimes, while complaints of instability are rare. Causes of SLAP lesion include the external force that affects biceps tendon, the instability of glenohumeral joint, etc. The rate of incidence for elderly is relatively low with degeneration as the common cause. Age is an important factor that affects the postoperative clinical result of SLAP repair. However, the elderly patient can still get good operation effects with effective postoperative rehabilitation therapy and the careful preoperative evaluation of patients' demands and operation risks. Tendectomy or tenodesis of long head of biceps brachii is an option for SLAP repair.Methods（1）General information. From January 2014 to January 2015, 35 patients with type II and IV SLAP lesions treated with shoulder arthroscopy in our hospital were retrospectively analyzed. Seventeen cases （9 males and 8 females） treated with long head of biceps brachii tendectomy and intertubercular sulcus extra-articular drilling and tenodesis （Group A） aged from 51 to 68 years with an average of 58.6 years, including 7 cases of left and 10 cases of right.Eighteen cases （11 males and 7 females） treated with long head of biceps brachii tendectomy and intraarticular tenodesis （Group B） aged from 51-68 years with an average of 59.8 years, including 8 cases of left and 10 cases of right. Before operation, the diagnosis of glenoid labrum injury was confirmed by history taking, physical examination and MRI examination. Relevant examinations and preparations were refined preoperatively without absolute contraindication of surgery and anesthesia.（2）Inclusive criteria.① The age was more than 50 years;②The symptoms of snapping and mechanical interlocking lasted for 3-6 months, and the rehabilitation exercise has no effect; ③The formal conservative treatment was ineffective for 6-8 months;④ Patients with shoulder instability. （3）Exclusive criteria. ①Patients with habitual shoulder dislocation; ②Patients with subacromial tenderness caused by subacromial bursitis; ③Patients with open wound or infection on shoulder; ④ Patients with injuries of other parts of body which made the execution of surgery impossible temporarily; ⑤ Patients with other chronic disease and infectious disease which made them unfit for surgical treatment.（4）Operative methods.After general anesthesia, the patient was in beach chair position with routine disinfection and draping. The anterolateral, posterior and anterior approaches of shoulder joint were applied to perform arthroscopy. The glenohumeral joint structure was explored initially during the operation to confirm the injury type （II or IV） of glenoid labrum. Meanwhile, other lesions such as synovial hyperplasia, intraarticular loose bodies, joint capsule relaxation, glenoid bone defects, etc. were checked. Corresponding treatments were given accordingly. For instance, the management of hyperplastic synovial membrane and the removal of loose bodies could be carried out in priority. The treatment of wound or the removal of bone cortex was carried out with plane blade or grinding drill till the obtain of bleeding or fresh bone wound which facilitated the healing of glenoid labrum after reattachment. The choice of applying anchor fixation repair or not on SLAP lesion depended on the situation of the intraoperative debridement of glenoid labrum. Then, the long head tendon of biceps was cut off under arthroscopy, which was treated with intra-articular tenodesis or extra-articular intertubercular sulcus drilling and tenodesis. The wound was irrigated with a large amount of saline to prevent the drainage tube from plasma blockage, and the incision was sutured.（5）Postoperative management.The patient was given anti-infection, analgesia and discontinuous ice compress, and the shoulder joint was immobilized with brace in abduction position. The drainage tube was removed on the second day after operation. Following the step-by-step process, fist clenching and active and passive elbow movements were executed within 2 weeks postoperatively. The passive anteflexion, abduction and dorsiflexion of ipsilateral shoulder joint were carried out gradually. The painless active anteflexion, abduction and dorsiflexion of ipsilateral shoulder joint were conducted gradually 3 weeks later, and the painless full range activity of affected shoulder was started 6 weeks later. Muscle strength training was carried out 3 months after operation, and the original sports level was restored 6 months postoperatively.（6）Evaluating criteria.The function and ache situation of shoulder joint were evaluated preoperatively and postoperatively by the Rating scales of America shoulder and elbow surgeon's score （ASES） and visual analog scale （VAS）. The total score of ASES is 100 points, including 36 points for pain, 36 points for stability and 28 points for function. The higher the score, the better the shoulder function. The total VAS score is 10 points. 0 point: painless; 3 points or less: mild pain that is endurable; 4-6 points: moderate pain that affects sleep and is tolerable; 7-10 points:gradually intense pain that is intolerable and affects appetite and sleep.（7）Statistical analysis. The SPSS17.0 statistical software was used for data analysis. The measurement data was represented as x-±s with t test, and P ＜0.05 was considered as statistical difference.ResultsAll patients were followed up for 1 year. The postoperative ASES and VAS scores improved significantly compared to those before operation, and the differences between preoperative scores and postoperative scores were statistically significant（P ＜0.05）. The operation time between the two groups had no statistical difference （P＞0.05）. No patient had nerve injury, wound infection and other complications.ConclusionsIn treating senile SLAP lesion, the arthroscopic long head of biceps brachii tendectomy and intertubercular sulcus extra-articular tenodesis achieves definite clinical effect, minor surgical trauma, few complications, early functional exercises and quick function recovery. Hence, it is a minimal invasive method that is worth of promotion.Compared to that of knee arthroscopy, however, the operation technique of shoulder arthroscopy has high difficulty and long learning curve. Thus, it requires joint athletic injury specialists who are skilled and experienced in arthroscopy operation to achieve ideal surgical effects.

Arthroscopy; Long head of biceps tendon; Intertubercular sulcus; Elderly patients;SLAP lesion

10.3877/cma.j.issn.2095-5790.2017.03.005

西南医科大学应用基础研究计划项目（2015-YJ049）；西南医科大学附属中医医院联合专项项目（2016-4-25）；西南医科大学附属中医医院联合专项项目（2016-4-4）

646000 泸州， 西南医科大学附属中医医院骨关节科

扶世杰，Email：fu_fsj@sina.com

2016-07-05）

（本文编辑：李静；英文编辑：陈建海、张晓萌、张立佳）

赵加松,汪国友,曾胜强,等. 肱二头肌长头腱切断结节间沟下关节外固定治疗老年SLAP损伤患者的疗效分析［J/CD］.中华肩肘外科电子杂志,2017,5（3）：180-185.