劉玉雷 敖英芳 閆輝 崔國(guó)慶

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·論著·

關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)治療全層肩袖撕裂的中期療效

劉玉雷 敖英芳 閆輝 崔國(guó)慶

目的 評(píng)估關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)治療肩袖全層撕裂的中期療效。方法 回顧性分析2010年3月至2011年2月應(yīng)用關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)治療的45例全層肩袖撕裂患者的術(shù)后效果。分別測(cè)定患者術(shù)前、術(shù)后休息和運(yùn)動(dòng)時(shí)的疼痛視覺(jué)模擬評(píng)分(visualanalogscale,VAS)，肩關(guān)節(jié)前屈、外展和體側(cè)外旋角度，美國(guó)加州大學(xué)肩關(guān)節(jié)評(píng)分(UniversityofCaliforniaatLosAngeles,UCLA)和美國(guó)肩與肘協(xié)會(huì)評(píng)分系統(tǒng)(Americanshoulderandelbowsurgeon′sform,ASES)，并在術(shù)后對(duì)患者進(jìn)行核磁共振(magneticresonanceimaging,MRI)檢查。結(jié)果 術(shù)后平均隨訪時(shí)間61.5個(gè)月(56～67個(gè)月)，41例患者獲得隨訪，隨訪率91.1%。與術(shù)前相比：休息時(shí)(Z=5.182，P<0.01)和活動(dòng)時(shí)(Z=5.544，P<0.01)的VAS評(píng)分明顯改善；前屈角度(Z=5.042，P<0.01)、外展角度(Z=5.060，P<0.01)和體側(cè)外旋角度(Z=4.636，P<0.01)增加差異有統(tǒng)計(jì)學(xué)意義；UCLA評(píng)分(Z=5.584，P<0.01)和ASES評(píng)分(Z=5.580，P<0.01)明顯改善，差異有統(tǒng)計(jì)學(xué)意義?；颊邔?duì)手術(shù)的滿意率是100%，無(wú)術(shù)中和術(shù)后并發(fā)癥。術(shù)后MRI檢查有6例(19.4%)表現(xiàn)為再撕裂，其中1例(16.7%)位于腱骨交界處，5例(83.3%)位于腱腹交界處。結(jié)論 關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)治療全層肩袖撕裂的中期療效滿意。

肩關(guān)節(jié)；肩袖撕裂；關(guān)節(jié)鏡；縫合橋技術(shù)

目前，關(guān)節(jié)鏡下肩袖修復(fù)技術(shù)主要包括單排縫合、雙排縫合和雙排縫合橋固定技術(shù)，其中雙排縫合橋固定技術(shù)由于使肌腱和肱骨頭止點(diǎn)接觸面積更大而引起廣泛關(guān)注。生物力學(xué)試驗(yàn)[1-2]和動(dòng)物試驗(yàn)[3]已證實(shí)雙排縫合橋固定技術(shù)相比另兩種技術(shù)的優(yōu)勢(shì)是使肌腱和足跡點(diǎn)的接觸面積更大，接觸壓力和失效負(fù)荷更高，從而能夠保證更加良好的愈合。在近年臨床研究方面，有不少報(bào)道應(yīng)用雙排縫合橋固定技術(shù)治療不同大小肩袖撕裂均獲得較好的臨床效果。但是，這些臨床研究的隨訪時(shí)間均較短，隨訪時(shí)間為9.7～27.4個(gè)月[4-11]。另一方面，在通過(guò)MRI、MRA或B超檢查評(píng)估術(shù)后肩袖止點(diǎn)的完整性時(shí)，雙排縫合橋固定技術(shù)的再撕裂率在不同研究中差異較大(4.7% ～48.4%)[7, 12-16]。同時(shí)，再撕裂的位置是常見(jiàn)于縫合肌腱與足跡的交界處還是常見(jiàn)于腱腹交界處也尚未形成共識(shí)[7,15,17]。本研究所曾報(bào)道過(guò)關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)并獲得了良好的早期療效[6]，本研究的目的是進(jìn)一步評(píng)估此技術(shù)修復(fù)全層肩袖撕裂的中期療效并通過(guò)術(shù)后的MRI檢查客觀地了解肩袖縫合后止點(diǎn)處的腱骨愈合的情況。

資 料 與 方 法

一、一般資料

回顧性分析北京大學(xué)第三醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)研究所于2010年3月至2011年2月連續(xù)收治行關(guān)節(jié)鏡下雙排縫合橋固定技術(shù)的全層肩袖撕裂患者45例，其中男性23例，女性22例；平均年齡52.2歲(21～78歲)。

本研究方案已獲得北京大學(xué)第三醫(yī)院醫(yī)學(xué)科學(xué)研究倫理委員會(huì)批準(zhǔn)及所有入選患者的知情同意。

二、納入及排除標(biāo)準(zhǔn)

納入標(biāo)準(zhǔn)：(1)年齡>18歲；(2)肩袖全層撕裂；(3)有關(guān)節(jié)鏡手術(shù)指征；(4)患者同意參與本研究。

排除標(biāo)準(zhǔn)：患者存在部分撕裂，需要鎖骨遠(yuǎn)端切除的肩鎖關(guān)節(jié)炎、盂肱關(guān)節(jié)骨關(guān)節(jié)炎、二頭肌長(zhǎng)頭腱撕裂、行翻修手術(shù)和術(shù)后隨訪期間再受傷的除外。

三、手術(shù)方法

手術(shù)均由同一名醫(yī)師完成?；颊卟捎萌砺樽恚吧碁┮巍蔽?。 經(jīng)后入路進(jìn)入肩峰下間隙，建立肩峰外側(cè)通道。清理肩峰下滑囊，并根據(jù)有無(wú)撞擊表現(xiàn)決定是否同時(shí)行肩峰成形術(shù)。通過(guò)附加外側(cè)入路，松解肌腱粘連，清理殘端和新鮮化足跡處的骨床，用雙排縫合橋技術(shù)將撕裂的肩袖組織縫合于足跡處[6]。

四、評(píng)估方法

根據(jù)DeOrio和Cofield的分級(jí)標(biāo)準(zhǔn)[18]，關(guān)節(jié)鏡術(shù)中從外側(cè)入路觀察，從后入路應(yīng)用帶刻度的探鉤測(cè)量撕裂前后徑大小，將肩袖撕裂分為小撕裂(<1cm)、中撕裂(1～3cm)、大撕裂(3～5cm)和巨大撕裂(>5cm)。所有患者術(shù)前1d和術(shù)后隨訪時(shí)進(jìn)行肩關(guān)節(jié)量表評(píng)估和體格檢查。功能評(píng)分采用美國(guó)加州大學(xué)肩關(guān)節(jié)評(píng)分(universityofCaliforniaatLosAngeles,UCLA)[19]和美國(guó)肩與肘協(xié)會(huì)評(píng)分(Americanshoulderandelbowsurgeon′sform,ASES)[20]。術(shù)前、術(shù)后的疼痛程度用休息時(shí)和活動(dòng)時(shí)的疼痛視覺(jué)模擬評(píng)分法(visualanalogscale，VAS)來(lái)評(píng)價(jià)。肩關(guān)節(jié)活動(dòng)范圍測(cè)量包括前屈、外展和體側(cè)外旋(肩關(guān)節(jié)中立位，屈肘90°測(cè)量)的角度，后伸受限的程度以能否觸摸到對(duì)側(cè)肩胛骨為標(biāo)準(zhǔn)。

注：VAS：疼痛視覺(jué)模擬評(píng)分；UCLA：美國(guó)加州大學(xué)肩關(guān)節(jié)評(píng)分；ASES：美國(guó)肩與肘協(xié)會(huì)評(píng)分

縫合后肩袖組織愈合的完整性用1.5T-MRI(Sonata,Siemens)評(píng)估。評(píng)價(jià)標(biāo)準(zhǔn)采用Sugaya分級(jí)標(biāo)準(zhǔn)[21]：Ⅰ型：修復(fù)的肩袖在每個(gè)層面中均連續(xù)性完整、有正常的厚度并且信號(hào)均一；Ⅱ型：肩袖連續(xù)性完整、有正常的厚度，局部可見(jiàn)高信號(hào)區(qū)域；Ⅲ型：修復(fù)的肩袖厚度不足正常肩袖的一半，但無(wú)不連續(xù)，提示部分層裂；Ⅳ型：在斜冠狀面和矢狀面上均可見(jiàn)1～2個(gè)層面存在不連續(xù)信號(hào)，提示小的全層撕裂；Ⅴ型：在斜冠狀面和矢狀面上均可見(jiàn)2個(gè)層面以上存在大的信號(hào)不連續(xù)區(qū)域，提示中或大撕裂。Ⅳ型和Ⅴ型的患者被認(rèn)為存在再撕裂。為了進(jìn)一步分析再撕裂的位置，我們按照Cho的標(biāo)準(zhǔn)將再撕裂分為2型。Ⅰ型：縫合的肩袖組織沒(méi)有附著在大結(jié)節(jié)上。Ⅱ型：發(fā)生再撕裂的區(qū)域沒(méi)有位于修復(fù)止點(diǎn)的殘端處[22-23]。

五、統(tǒng)計(jì)學(xué)方法

由于數(shù)據(jù)正態(tài)性不佳，故采用中位數(shù)與四分位數(shù)間距描述數(shù)據(jù)，采用非參數(shù)Wilcoxon秩和檢驗(yàn)比較術(shù)前和術(shù)后評(píng)價(jià)指標(biāo)的差異。P<0.01被認(rèn)為差異有統(tǒng)計(jì)學(xué)意義。所有描述性和分析性統(tǒng)計(jì)都采用WindowsXP下的SPSS21.0進(jìn)行。

結(jié) 果

一、一般結(jié)果

共計(jì)41例患者獲得隨訪，隨訪率91.1%。平均隨訪時(shí)間為61.5個(gè)月(56～67個(gè)月)，4例失訪的患者中，1例患者因其他原因死亡，1例患者定居國(guó)外，2例患者無(wú)法聯(lián)系。獲得隨訪的患者中，男性20例，女性21例；平均年齡52.1歲(21～78歲)；術(shù)前平均病程13.6個(gè)月(0.3～60個(gè)月)；左肩15例，右肩26例。23例患者累及優(yōu)勢(shì)肩。關(guān)節(jié)鏡發(fā)現(xiàn)小撕裂12例(29.3%)、中撕裂20例(48.8%)、大撕裂5例(12.2%)和巨大撕裂4例(9.8%)。

二、疼痛評(píng)分和功能測(cè)定結(jié)果

術(shù)前、術(shù)后的VAS評(píng)分、關(guān)節(jié)活動(dòng)度、UCLA和ASES評(píng)分結(jié)果見(jiàn)表1。休息時(shí)(Z=5.182，P<0.01)和活動(dòng)時(shí)(Z=5.544，P<0.01)的VAS評(píng)分均較術(shù)前明顯改善。與術(shù)前相比，術(shù)后前屈角度(Z=5.042，P<0.01)、外展角度(Z=5.060，P<0.01)和體側(cè)外旋角度(Z=4.636，P<0.01)增加均有統(tǒng)計(jì)學(xué)意義。隨訪時(shí)仍然存在后伸受限的有13例(13.7%)，其中能摸到對(duì)側(cè)肩胛骨的6例(14.6%)，不能摸到對(duì)側(cè)肩胛骨的7例(17.1%)。盡管如此，這些患者的后伸受限均不影響生活。術(shù)后UCLA評(píng)分(Z=5.584，P<0.01)和ASES評(píng)分(Z=5.580，P<0.01)較術(shù)前明顯改善，差異有統(tǒng)計(jì)學(xué)意義?；颊邔?duì)手術(shù)的滿意率是100%，無(wú)術(shù)中和術(shù)后并發(fā)癥，無(wú)神經(jīng)、血管損傷及感染患者。

三、核磁共振(MRI)結(jié)果

術(shù)后有31例患者在本院進(jìn)行了MRI檢查，根據(jù)Sugaya分型，Ⅰ型(圖1)7例(22.6%)，Ⅱ型(圖2)15例(48.4%)，Ⅲ型(圖3)3例(9.7%)，Ⅳ型(圖4)6例(19.4%)，Ⅴ型0例。即有6例(19.4%)患者的術(shù)后MRI表現(xiàn)為再撕裂。4例巨大撕裂中有3例完成了術(shù)后MRI檢查，Sugaya分型均為Ⅱ型。5例大撕裂中有4例完成了術(shù)后MRI檢查，其中1例為Ⅰ型，2例為Ⅱ型，1例為Ⅲ型。根據(jù)Cho分型，再撕裂Ⅰ型(圖4)：1例(16.7%)，Ⅱ型(圖5)：5例(83.3%)。

圖1 術(shù)后MRI示Sugaya Ⅰ型，修復(fù)的肩袖連續(xù)性完整、有正常的厚度并且信號(hào)均一

討 論

近年來(lái)，應(yīng)用雙排縫合橋技術(shù)修復(fù)全層肩袖撕裂受到廣泛關(guān)注。在基礎(chǔ)研究方面，生物力學(xué)試驗(yàn)和動(dòng)物試驗(yàn)均已證實(shí)雙排縫合橋固定技術(shù)相比傳統(tǒng)的單排和雙排固定技術(shù)更具優(yōu)勢(shì)，它可以使肌腱和足跡點(diǎn)的接觸面積更大，接觸壓力和失敗負(fù)荷更高，從而能夠保證更加良好的愈合[1-3]。

在臨床研究方面，有不少報(bào)道應(yīng)用雙排縫合橋固定技術(shù)治療不同大小肩袖撕裂均獲得較好的臨床效果。但是，這些臨床研究的隨訪時(shí)間均較短，為9.7～27.4個(gè)月[4-11]。本研究在既往研究的基礎(chǔ)上，進(jìn)一步的評(píng)估了雙排縫合橋技術(shù)修復(fù)全層肩袖撕裂的中期療效(平均隨訪61.5個(gè)月)，發(fā)現(xiàn)患者術(shù)后的疼痛、臨床評(píng)分和功能均較術(shù)前明顯改善，術(shù)中和術(shù)后未出現(xiàn)并發(fā)癥，這提示其中期療效安全、可靠，值得推廣。

圖2 術(shù)后MRI示Sugaya Ⅱ型，修復(fù)的肩袖連續(xù)性完整、有正常的厚度，局部可見(jiàn)高信號(hào)區(qū)域

圖3 術(shù)后MRI示Sugaya Ⅲ型，修復(fù)的肩袖厚度不足正常肩袖的一半，但無(wú)不連續(xù)，提示部分層裂

圖4 術(shù)后MRI示Sugaya Ⅳ型，修復(fù)的肩袖存在不連續(xù)信號(hào)，提示小的全層撕裂(按照Cho的分型方法分為1型)

圖5 術(shù)后MRI示再撕裂位于內(nèi)排釘以內(nèi)，即腱腹交界處(按照Cho的分型方法分為2型)

回顧文獻(xiàn)，通過(guò)影像學(xué)評(píng)估單排技術(shù)修復(fù)肩袖撕裂解剖失敗率為22%～25%[23-24]，雙排技術(shù)由于可獲得更好的生物力學(xué)特性和足跡的完整性，其再撕裂率較低，為11%～17%[25- 26]。而雙排縫合橋技術(shù)的再撕裂率在不同研究中變異較大(4.7% ～ 48.4%)，尚未形成共識(shí)。Frank等[12]和Mihata等[14]用MRI評(píng)估縫合橋技術(shù)的再撕裂率時(shí)分別為12%和4.7%，低于其他的縫合方式。而其他學(xué)者報(bào)道的術(shù)后再撕裂率較高，Lee等[7]用MRA評(píng)估縫合后止點(diǎn)的再撕裂率，甚至高達(dá)48.8%。Cho等[15]用MRI評(píng)估的再撕裂率也高達(dá)33.3%，他們認(rèn)為再撕裂率較高可能與研究組中患者大撕裂或巨大撕裂所占比例較高(43.1%)有關(guān)。Kim等[16]報(bào)道了對(duì)巨大撕裂患者應(yīng)用縫合橋技術(shù)修復(fù)后的再撕裂率高達(dá)42.4%，Choi等[11]也認(rèn)為術(shù)中發(fā)現(xiàn)撕裂大小與術(shù)后再撕裂率高低明顯相關(guān)。由此可見(jiàn)，研究組中大撕裂或巨大撕裂患者所占比例多少是目前報(bào)道術(shù)后再撕裂率不統(tǒng)一的重要因素。盡管如此，Hein等[27]在最近的系統(tǒng)回顧中統(tǒng)計(jì)了32篇文章2 048例患者的術(shù)后再撕裂率，總體上，雙排縫合橋技術(shù)的再撕裂率為21%，而對(duì)161例巨大撕裂患者的術(shù)后MRI進(jìn)行統(tǒng)計(jì)，再撕裂率則高達(dá)40%。本組患者中，總體上術(shù)后MRI檢查再撕裂率為19.4%，與文獻(xiàn)相符。其中大撕裂或巨大撕裂占22%，術(shù)后MRI均無(wú)再撕裂表現(xiàn)，明顯優(yōu)于文獻(xiàn)。但由于本組中大撕裂或巨大撕裂例數(shù)較少(9例)，需要進(jìn)一步研究。同時(shí)我們注意到，在術(shù)后早期(平均隨訪時(shí)間9.7個(gè)月)對(duì)這批患者隨訪時(shí)，對(duì)手術(shù)不滿意的3例患者均來(lái)自于大撕裂或巨大撕裂組[6]，而在這次中期隨訪中，患者的滿意率為100%，且臨床評(píng)分和功能均較早期隨訪時(shí)明顯改善?？梢?jiàn)，對(duì)于大撕裂或巨大撕裂患者，術(shù)后康復(fù)時(shí)間較長(zhǎng)，MRI再撕裂率較高，需要重點(diǎn)關(guān)注。

關(guān)于用雙排縫合橋技術(shù)修復(fù)肩袖撕裂術(shù)后再撕裂的位置，許多學(xué)者進(jìn)行了研究，結(jié)果尚未統(tǒng)一。Cho等[22]和Lee等[7]認(rèn)為再撕裂大多位于腱腹交界處，他們報(bào)道的比例分別為74.1%和66.7%。相反的，在Neyton的患者中，11例再撕裂的患者僅有1例位于腱腹交界處，他們解釋為調(diào)整了內(nèi)排錨釘和縫線的數(shù)量、間距和松緊程度以避免給肌腱內(nèi)側(cè)過(guò)大的張力[17]。本研究的患者中發(fā)生再撕裂位于止點(diǎn)位置的占16.7%，位于腱腹交界處的占83.3%，與Cho和Lee的報(bào)道類似。一方面，這進(jìn)一步證明了縫合橋技術(shù)通過(guò)增加止點(diǎn)的接觸面積和壓力而促進(jìn)腱骨愈合，從而可以保證修復(fù)后良好的生物力學(xué)強(qiáng)度；但另一方面，它也提示內(nèi)排縫合過(guò)大的張力可能會(huì)影響肌腱的血運(yùn)和微循環(huán)，或者導(dǎo)致肌腱的局部扭轉(zhuǎn)。因此，為了減少術(shù)后再撕裂率，作者建議縫合內(nèi)排組織的錨釘和縫線間距要合理安排，不要過(guò)密，同時(shí)內(nèi)排縫線打結(jié)時(shí)不要過(guò)緊。

雙排縫合橋技術(shù)修復(fù)肩袖撕裂術(shù)后影像學(xué)提示再撕裂率的患者是否意味著其臨床效果和功能就差尚存在爭(zhēng)議。Cho等[22]報(bào)道的再撕裂率高達(dá)33.3%，但患者術(shù)后UCLA評(píng)分和日常生活均明顯改善，疼痛緩解。在Lee等[7]的隨訪中，術(shù)后MRA發(fā)現(xiàn)再撕裂率高達(dá) 48.4%，而術(shù)后肩關(guān)節(jié)活動(dòng)度、韓國(guó)肩關(guān)節(jié)評(píng)分、Constant評(píng)分和UCLA評(píng)分均較術(shù)前明顯改善。止點(diǎn)完整組和再撕裂組無(wú)統(tǒng)計(jì)學(xué)差別。相反的，Neyton等[17]在對(duì)中撕裂和小撕裂患者研究時(shí)，再撕裂組術(shù)后Constant評(píng)分明顯低于愈合組。Kim等[16]在對(duì)巨大撕裂患者研究中，再撕裂組VAS評(píng)分，UCLA評(píng)分和Constant評(píng)分均較愈合組差。在本組中，MRI評(píng)估為再撕裂的6例患者的VAS評(píng)分、臨床評(píng)分和關(guān)節(jié)活動(dòng)度均較術(shù)前明顯改善，患者對(duì)手術(shù)效果均滿意，這提示通過(guò)MRI評(píng)估縫合后肩袖止點(diǎn)的完整性不影響臨床效果。當(dāng)然，由于本組再撕裂患者例數(shù)較少，需要擴(kuò)大樣本量進(jìn)行統(tǒng)計(jì)學(xué)研究更有說(shuō)服力。

本研究存在一定的局限性。首先，不是前瞻性隨機(jī)研究。第二，本組患者中沒(méi)有包括其他手術(shù)方式進(jìn)行比較或作為對(duì)照組。第三，患者的樣本量較小可能導(dǎo)致偏倚。最后，由于隨訪時(shí)間較長(zhǎng)，臨床評(píng)估和MRI均有少量的失訪。盡管如此，本臨床研究表明關(guān)節(jié)鏡下雙排縫合橋技術(shù)應(yīng)用于肩袖修復(fù)的中期臨床效果滿意，是一種治療全層肩袖撕裂的安全有效的手術(shù)技術(shù)。

志謝 衷心感謝北京大學(xué)醫(yī)學(xué)部公共衛(wèi)生學(xué)院任正洪老師在數(shù)據(jù)統(tǒng)計(jì)方面給予的無(wú)私幫助。

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(本文編輯：胡桂英)

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Themid-termoutcomesafterarthroscopicrotatorcuffrepairusingasuturebridgetechniqueforpatientswithfull-thicknessrotatorcufftears

LiuYulei,AoYingfang,YanHui,CuiGuoqing.

InstituteofSportsMedicine,PekingUniversityThirdHospital,Beijing100191,China

Correspondingauthor:CuiGuoqing,Email：cgq3019@vip.163.com

Background Recently, arthroscopic rotator cuff repair using a suture bridge technique has been a popular, well-described surgical procedure. Arthroscopic techniques using 2 rows of fixation with crossed and interconnected sutures have been the subject of growing interest because they provide improved tendon-to-bone contact and compression over the anatomic footprint, therefore achieving high initial fixation strength and potentially improving healing. This was confirmed not only in biomechanical studies but also in animal experiments. In the aspect of clinical research, several studies on the suture bridge repair technique have been reported, which have obtained satisfactory functional results in 9.7 to 27.4 postoperative months. However, the mid-to long-term follow-up has not been conducted yet. In addition, structural failures still occur with suture-bridge repairs, and the reported retear rates range from 4.7% to 48.4%,as evaluated using magnetic resonance imaging(MRI),magnetic resonance angiography, or B ultrasonography. Although the clinical impact of rotator cuff retears remains controversial, several studies have shown that retears affect functional recovery. Regarding the location of failure, whether retears mostly occur at the tendon-bone interface or near the musculotendinous junction remains unknown. The present study was conducted to evaluate the mid-term outcomes of arthroscopic rotator cuff repair using a suture bridge technique in patients with full-thickness rotator cuff tears through clinical assessment and MRI.Methods Between March 2010 and February 2011, 45 patients with full-thickness rotator cuff tear were treated with the arthroscopic suture bridge repair technique and followed-up with MRI. The cuff tear size was defined as the length of the longest diameter measured with probes during surgery. The tear sizes were categorized into small (<1 cm), medium (1 to 3 cm), large (3 to 5 cm), and massive (>5 cm), according to the DeOrio and Cofield classification. Clinical and functional outcomes were assessed on the basis of the visual analog pain scale (VAS) score, range of motion (ROM), the University of California at Los Angeles (UCLA) rating scale score, and the American Shoulder and Elbow Surgeons (ASES) shoulder index. Radiological outcome was evaluated with follow-up MRI, which was performed using a 1.5-Tesla scanner (Sonata, Siemens, Germany). According to Sugaya′s classification, postoperative cuff integrity was classified into 5 categories using oblique coronal, oblique sagittal, and transverse views of T2-weighted images as follows: type Ⅰ, the repaired cuff appeared to have a sufficient thickness compared with that of the normal cuff, with homogeneously low intensity on each image; type Ⅱ, the repaired cuff had a sufficient thickness compared with that of the normal cuff and was associated with a partially high-intensity area; type Ⅲ, the repaired cuff had an insufficient thickness, which was less than half the thickness of the normal cuff, but without discontinuity, suggesting a partial-thickness delaminated tear; type Ⅳ, presence of a minor discontinuity in only 1 or 2 slices on both oblique coronal and sagittal images, suggesting a small full-thickness tear; and type Ⅴ, presence of a major discontinuity in more than 2 slices on both oblique coronal and sagittal images, suggesting a medium or large full-thickness tear. Types Ⅳ and Ⅴ were considered retears. Retear patterns were classified according to the classification of Cho et al. as follows: type 1, no remnant of the cuff tissue repaired at the insertion site of the rotator cuff, on the greater tuberosity; or type 2, with remnant cuff tissue at the insertion site despite retear. All operations were performed by a single senior surgeon, with the patient under general anesthesia in the beach-chair position. Four routine arthroscopic portals (anterior, posterior, anteriolateral, and lateral) were used to perform rotator cuff repair. A posterior portal was established as the primary viewing portal. After bursectomy, acromioplasty was performed on the basis of preoperative plain radiographs and arthroscopic findings that revealed the appearance of severe impingement at the undersurface of the acromion. The bursal side of the rotator cuff was then inspected, and the margin of the tear, especially the delaminated surfaces, was debrided to obtain fresh tendon tissues. The coracohumeral ligament, superior capsule, and/or rotator interval were released as needed to maximize the mobility of the rotator cuff before the repair, so that the tissue edges could be easily reduced over the greater tuberosity with the use of a grasper. For cases combined with a subscapularis tendon tear, a suture for the subscapularis was performed first. The footprint on the greater tuberosity was debrided thoroughly of soft tissue and burred until bleeding occurred. To insert a suture anchor, the suture anchor portal was made just lateral to the acromion. A Bio-Corkscrew suture anchor (4.5 or 5.5 mm, Arthrex, Naples, FL) was inserted at the junction of the articular cartilage and the medial aspect of the footprint on the greater tuberosity. The number of anchors used was 1 or 2, depending on the tear size. After that, the torn rotator cuff was pulled with a grasper, and a proper suture site was determined. Sutures were passed through the whole tendon in a horizontal mattress manner with SMC knots, one of the sliding knots. Suture bridge repair was then performed by placing 2 knotless lateral row PushLock anchors (3.5 or 4.5 mm Bio-PushLock, Arthrex) that held at least 1 suture strand from each of the medial row mattress knots. While constant tension was maintained, the PushLock anchors were inserted in the lateral aspect of the greater tuberosity, with the sutures providing proper pressure across the rotator cuff footprint. Then, the sutures were cut. An identical rehabilitation protocol was applied in all the patients. Pendulum and active elbow range-of-motion exercises were started immediately after surgery. Passive forward flexion was started 3 days after surgery. Early ROM was permitted in a tolerable range. Immobilization was maintained with an abduction brace for 6 weeks. Active joint and muscle strengthening exercises were performed from the sixth postoperative week. Particularly for a massive rotator cuff tear, immobilization was maintained for 3 months. After that, the active joint strengthening exercise was started. Return to recreational activity or manual labor was permitted 6 months after the operation. Nonparametric tests were used to assess the differences between preoperative and postoperative results for clinical and functional evaluations. The SPSS software was used for all statistical analyses, with the significance level set at 0.01.Results Forty-one patients returned for a functional evaluation with a follow-up rate of 91.1%. The mean time from surgery to the final follow-up functional evaluation was 61.5 months (range, 56-67 months). The mean age was 52.1 years (range, 21-78 years). Of the patients, 20 were men and 21 were women. The right shoulder was involved in 26 cases; and the left shoulder, in 15 cases. The mean duration of the rotator cuff tears was 13.6 months (range, 0.3-60 months). Twenty-three patients had involvement of the dominant arm. The cases comprised 12 (29.3%)small, 20 (48.8%) medium, 5 (12.2%) large, and 4 (9.8%) massive rotator cuff tears according to the arthroscopic examination. At the last follow-up, the postoperative VAS score at rest (Z=5.182，P<0.01)andduringmotion(Z=5.544,P<0.01)decreasedsignificantly.Thepostoperativerangeofmotionforforwardflexion(Z=5.042,P<0.01),abduction(Z=5.060,P<0.01),andexternalrotationattheside(Z=4.636,P<0.01)increasedsignificantly.Although13patients(13.7%)hadmildlimitationofinternalbackrotation,theirdailyliveswerenotaffected.Theoverallsatisfactionratewas100%.TheUCLAscore(Z=5.584,P<0.01)andASESshoulderindex(Z=5.580,P<0.01)improvedsignificantlyatpostoperativefollow-up.Nonerveinjury,deepinfection,oranchor-relatedcomplicationoccurred.ThepostoperativerepairintegritywasanalyzedbyusingMRIin31 (68.9%)ofthe45shoulders.AccordingtoSugaya′sclassification, 8patients(25.8%)hadtypeⅠpostoperativecuffintegrity; 15 (48.4%),typeⅡ; 2 (6.5%),typeⅢ; 6 (19.4%),typeⅣ;andnonehadtypeⅤ.Thus,MRIrevealedretearin6patients(19.4%).Threeof4patientswithmassiverotatorcufftearscompletedpostoperativeMRIexamination,andtheirtearswereallclassifiedastypeⅡ.Fourof5patientswithlargerotatorcufftearscompletedpostoperativeMRIexamination,ofwhom1hadatypeⅠtear, 2hadtypeⅡtears,and1hadatypeⅢtear.Inthepatientsconsideredashavingaretear,theretearoccurredatthegreatertuberosityin1patientandatthemusculotendinousjunctionin5patients.ConclusionsArthroscopicsuturebridgerepairoffull-thicknessrotatorcufftearswasfollowedbyaretearrateof19.4%,asassessedonMRI,andresultedinasignificantimprovementinmid-termclinicalresultsfromthepreoperativefindings.Retearsoccurredmainlyatthemusculotendinousjunction.

Shoulder;Rotatorcufftear;Arthroscopy;Suturebridgetechnique

10.3877/cma.j.issn.2095-5790.2015.04.005

高等學(xué)校博士學(xué)科點(diǎn)專項(xiàng)科研基金新教師類資助課題(20120001120070)

100191北京大學(xué)第三醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)研究所

崔國(guó)慶，Email：cgq3019@vip.163.com

2015-09-26)