肩袖損傷的關(guān)節(jié)鏡治療和總體介紹

1、肩袖損傷的關(guān)節(jié)鏡治療和總體介紹概念和功能由岡上肌、岡下肌、肩胛下肌及小圓肌之肌腱在肱骨頭前、上、后方形成的袖套樣肌樣結(jié)構(gòu)。在任何運動或靜止?fàn)顟B(tài)保持肱盂關(guān)節(jié)穩(wěn)定，并使之成為運動的軸心和支點維持上臂各種姿勢和完成各種運動功能。41325肩胛骨3. 喙突4. 肱骨頭5. 關(guān)節(jié)盂1. 鎖骨2. 肩峰肩關(guān)節(jié)解剖之骨骼41325肩胛骨3. 喙突4. 肱骨頭5. 關(guān)節(jié)盂1. 鎖骨2. 肩峰肩關(guān)節(jié)骨骼肩袖解剖肩袖解剖組成和功能岡上肌(肩胛上神經(jīng)) :上臂外展并固定肱骨頭于肩盂上并防止肱骨頭上移岡下肌(肩胛上神經(jīng)):上臂下垂位時使上臂外旋小圓肌(腋神經(jīng)):臂外旋肩胛下肌(肩胛下神經(jīng)):臂下垂位時內(nèi)旋肩關(guān)節(jié)病因退

2、變學(xué)說血運學(xué)說撞擊學(xué)說創(chuàng)傷學(xué)說岡上肌止點附近血供來源于大結(jié)節(jié)骨膜滋養(yǎng)血管，肌腹血供來源于肩胛上動脈，而止點近端1 cm處有明顯的乏血管區(qū)肩峰發(fā)育異常、肩鎖關(guān)節(jié)增生肥大、高位肱骨大結(jié)節(jié)、肩峰下骨贅形成肩峰下撞擊綜合征分類按損傷程度： 挫傷 不完全斷裂 完全斷裂分類按斷裂口方向 橫行 縱行按肌腱斷裂范圍小型撕裂：單一肌腱撕裂范圍小于肌腱橫徑1/2 大型撕裂：單一肌腱撕裂范圍大于肌腱橫徑1/2 廣泛撕裂：范圍累及兩個及兩個以上的肩袖肌腱，伴有肩袖組織的退縮缺損臨床表現(xiàn)臨床表現(xiàn)外傷史：急性損傷、重復(fù)性或累積性損傷史疼痛與壓痛：多位于肩前方 活動或增加負(fù)荷后加重 被動外旋或過度內(nèi)收時加重 夜間癥狀加重功

3、能障礙：上舉和外展功能受限肌肉萎縮：3周繼發(fā)性關(guān)節(jié)攣縮：3月 當(dāng)我們在臨床上遇到疑似病人，只有X片而無MRI檢查時，1 我們能從X片中得到什么信息？2 我們印象中的可疑診斷有哪些？3 針對性的體查有哪些？ Gazzola S, Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9. cystic change of the greater tuberosity1 讀X片Gazzola S, Bleakney RR.Current imaging of the rotator c

4、uffJ.Sports Med Arthrosc,2011,19(3):300-9. normal subacromial joint space (7mm) (arrow)1 superior subluxation of the humeral head (arrow)2 notched humeral neck (arrowhead)Type I calcication with a uffy, eecy appearance with poorly dened borders, with acute symptoms and termed the resorptive phase. T

5、ype II calcication, more discreet and of homogenous density, with well-circumscribed borders, and in the formative phase.DePalma AF, Kruper JS. Long-term study of shoulder joints affliated with and treated for calcic tendinitisJ. Clin Orthop.1961;20:61-72.calcic tendinopathy2 可疑診斷1 關(guān)于肩周炎 肩周炎=凍結(jié)肩（實用骨

6、科學(xué)第3版），是由于肩關(guān)節(jié)周圍軟組織病變而引起肩關(guān)節(jié)疼痛和活動功能障礙。國外報道 Frozen shoulder 40-60 years of age, incidence 2-5%1.3 phases2freezing phase 2-9 months, pain and loss of motion of the glenohumeral joint in all direction，usually worst at night and when lying on the affected side2) frozen phase 4-12 months, stiffness reaches

7、 its maximumthawing phase 5-12 months, range of motion returns to normal 2 肩峰下撞擊綜合癥 疼痛，主訴為三角肌下疼痛，并經(jīng)常向下放射至前方的肱二頭肌，夜間疼痛可影響睡眠1 Hand C, Clipsham K, Rees JL, et al. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg 2008;17:231-6.2 Reeves B. The natural history of the frozen shoulder syndrome. S

8、cand J Rheumatol 1975;4:193-6. 針對肩袖損傷的體查1 岡上肌 肩外展功能1 empty can test1) 90 degrees abduction2) 30 degrees horizontal abduction (in the plane of the scapula)3) thumbs pointing downward2 full can test1) 90 degrees in the horizontal plane2) rotated 45degrees externally3) with the thumb pointing upwardpai

9、nful arc test 60-1201) shoulder in external rotation2) palm facing up4 resisted isometric abduction1) the arm in neutral rotation2) abducts the arm to 90 degrees1 external rotation strength test=Pattes test1) the patients elbow in 90 degrees2) in the plane of the scapula2 岡下肌和小圓肌 肩外旋功能2 external rot

10、ation lag sign1) elbow passively flexed to 90 degrees2) maximal external rotation3 drop sign1) almost full external rotation2) elbow flexed at 90 degrees4 weakness with external rotation1) elbows flexed to 90 degrees2) the thumbs up3) shoulders rotated internally 20 degrees3 肩胛下肌 肩內(nèi)旋、后伸功能1 lift off

11、test asking the patient to internally rotate the arm to lift the hand posteriorly off of the back2 internal rotation lag sign3 belly press4 bear hug test4 針對肩峰下撞擊綜合癥的體查Hawkins-Kennedy test關(guān)于MRI肩袖解剖解剖足?。╢ootprint）關(guān)于MRI正常肩袖的MRI 斜冠狀面正常肩袖的MRI 斜矢狀面正常肩袖的MRI 橫斷面損傷肩袖的MRI魔法角 magic angle phenomenonthe fibers

12、are at 55 degrees to the main magnetic field on T1Erickson SJ, Prost RW, Timins ME. The “magic angle” effect: background physics and clinical relevance. Radiology. 1993;188:23-25.MRI上應(yīng)得到的信息1 肩袖走行及連續(xù)性2 高信號3 脂肪變性4 肌肉萎縮5 肌肉回縮6 三角肌下、肩峰下囊滑液相連 肩袖走行及連續(xù)性脂肪滲透（fatty infiltration）Fuchs B, Weishaupt D, Zanetti

13、M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599-605.肌肉萎縮（muscle atrophy）1 切線征1 （tangent sign）2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus mus

14、cle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa, and in supraspinatus atrophy the ratio is less than 50%2.1 Zanetti M, Gerber C, Hodler J. Quantitative assessment of themuscles of the rotator cuff with magnetic resonance imaging. Invest Radiol. 19

15、98;33:163-170.2 Thomazeau H, Rolland Y, Lucas C, et al. Atrophy of thesupraspinatus belly. Assessment by MRI in 55 patients withrotator cuff pathology. Acta Orthop Scand. 1996;67:264-268.肩袖損傷的分類1 全層撕裂 1）小 1cm 2）中 1-3cm 3）大 3-5cm 4）巨大 5cmDeOrio JK, Coeld RH. Results of a second attempt at surgical re

16、pair of a failed initial rotator-cuff repair. J Bone Joint Surg. 1984;66:563567.肩袖損傷的分類2 部分撕裂肩袖損傷的治療手術(shù) VS 保守 parameters in decision making for the surgery of the cuff1. 75 years2 撕裂大小 Shimizu2 recommend early cuff repair after conrming the diagnosis of massive rotator cuff tears.Partial-thickness ro

17、tator cuff tear is a further indication in those patients with minimal risk of tear extension, minimal pain, and dysfunction3.1 Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci. 2010;115:193-200. 2 Shimizu C, Horii

18、 M, Yamashita F, et al. Prognosis of massive rotator cuff tear. Chubuseisai. 1990;33:392.3 Ozbaydar MU, Bekmezci T, Tonbul M, et al. The results of arthroscopic repair in partial rotator cuff tears. Acta Orthop Traumatol Turc. 2006;40:4955.肩袖損傷的治療肌腱的縫法開放手術(shù)骨質(zhì)端的固定肩袖損傷的治療手術(shù)方式的選擇開放手術(shù) VS 關(guān)節(jié)鏡手術(shù)美國的一篇系統(tǒng)評價顯示

19、：術(shù)后6個月的ASES、UCLA、疼痛評分及再斷裂方面，兩者無顯著差異，只有短期疼痛，關(guān)節(jié)鏡優(yōu)于開放手術(shù)。Lindley K, Jones GL. Outcomes of arthroscopic versus open rotator cuff repair: a systematic review of the literature. Am J Orthop (Belle Mead NJ),2010,39(12):592-600.不可修復(fù)肩袖損傷的判定According to Gerber et al. , imaging ndings that suggest an irreparabl

20、e rotator cuff tear include 1）static superior subluxation of a glenohumeral joint with anacromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotationGerber C, Wirth SH, Farshad M (2011) Treatment options for massive rotator cuff tears. J Should Elb Surg 2

21、0:S20S29.and 2) fatty inltration of the rotator cuff muscles at stage three or greater. 不可修復(fù)肩袖損傷的治療1 肱三頭肌長頭截斷2 debridement associated with acromioplasty and bursectomy3 partial repair4 arthroscopic tuberoplasty5 tendon transfers 1) latissimus dorsi transfers-superolateral rotator cuff tears2) pector

22、alis major transfers-irreparable tears of the subscapularis muscle 3) deltoid ap4) trapezius muscle transferlatissimus dorsi transfers一篇關(guān)于背闊肌修復(fù)巨大撕裂肩袖損傷的系統(tǒng)評價結(jié)果顯示：在個月的隨訪期內(nèi)，Constant score, active forward elevation和active external rotation術(shù)后明顯優(yōu)于術(shù)前。Namdari S, Voleti P, Baldwin K, Glaser D, Huffman GR. La

23、tissimus dorsi tendon transfer for irreparable rotator cuff tears: a systematic review. J Bone Joint Surg Am,2012,94(10):891-8. Rotator Cuff 肩袖損傷撞擊通常在老年患者 (65+) 勾狀的肩峰和肩袖撞擊導(dǎo)致疼痛和附加的肩袖撕裂肩袖損傷通常地這種情況導(dǎo)致岡上肌損傷,然后是岡下肌很少情況下會損傷小圓肌 除非在極其嚴(yán)重的情況下,肩胛下肌損傷極其少見,處理也很困難 部分撕裂也非常常見,這種情況也是治療的人選Rotator Cuff 肩袖損傷四種主要的肩袖撕裂類型：

24、1）新月形撕裂2）U形撕裂3）L形和倒L形撕裂4）巨大回縮性不可移動性撕裂Rotator Cuff 肩袖損傷新月形撕裂 IS岡下肌 SS岡上肌Rotator Cuff 肩袖損傷U形撕裂 IS岡下肌 SS岡上肌Rotator Cuff 肩袖損傷L形撕裂 IS岡下肌 Sub肩胛下肌肌腱 RI肩袖間隙 SS岡上肌 CHL喙肱韌帶Rotator Cuff 肩袖損傷巨大回縮性不可移動性撕裂 IS岡下肌 Sub肩胛下肌肌腱 RI肩袖間隙 SS岡上肌 CHL喙肱韌帶前面?zhèn)让?后面肩峰下囊是個潛在的空間直到充滿了流體在關(guān)節(jié)鏡手術(shù)中肩峰下囊前面觀側(cè)面/后面觀肩袖由四塊肌肉和他們的肌腱組成1.2341. 肩胛下肌

25、 2. 岡上肌肩袖3. 岡下肌4. 小圓肌肩袖 關(guān)節(jié)鏡下觀Rotator CuffHumeral HeadRotator Cuff 肩袖損傷肱骨頭肩袖肱骨頭肩袖關(guān)節(jié)囊方向看肱骨頭方向看Rotator Cuff 肩袖損傷撞擊通常在老年患者 (65+) 勾狀的肩峰和肩袖撞擊導(dǎo)致疼痛和附加的肩袖撕裂肩袖損傷通常地這種情況導(dǎo)致岡上肌損傷,然后是岡下肌很少情況下會損傷小圓肌 除非在極其嚴(yán)重的情況下,肩胛下肌損傷極其少見,處理也很困難 部分撕裂也非常常見,這種情況也是治療的人選Rotator Cuff 肩袖損傷四種主要的肩袖撕裂類型：1）新月形撕裂2）U形撕裂3）L形和倒L形撕裂4）巨大回縮性不可移動性撕

26、裂Rotator Cuff 肩袖損傷新月形撕裂 IS岡下肌 SS岡上肌Rotator Cuff 肩袖修補(bǔ) Rotator Cuff肩袖修復(fù) 主要考慮因素 主要目標(biāo)減少活動疼痛 (SAD) 和恢復(fù)運動功能入路錨釘放置過線.打結(jié)Rotator Cuff 肩袖修復(fù)方式穿骨縫線帶線鉚釘選擇錨釘 肩袖損傷:TwinFix Ti 5.0 mm: 骨質(zhì)疏松，需要高固定強(qiáng)度.多個縫線 肩關(guān)節(jié)不穩(wěn)(Bankart and SLAP) TwinFix Ti 3.5 mm: 此錨釘可以用于所有手術(shù)，包括肩袖損傷肩關(guān)節(jié)不穩(wěn)(Bankart and SLAP)TwinFix Ti 2.8 mm: 關(guān)節(jié)盂表面較小，醫(yī)生需

27、選擇較小的錨釘，但是也需要很高的拔出強(qiáng)度. 選擇使用單線孔錨釘，對于縫線的操作比較簡單肩袖損傷及肩關(guān)節(jié)不穩(wěn)TwinFix Ti Suture Anchor Range with Needles如醫(yī)生進(jìn)行開放手術(shù)，選擇帶針的縫線錨釘.Rotator Cuff肩袖修復(fù)應(yīng)用3個入路在這個手術(shù)過程中-后側(cè),前側(cè),側(cè)面的工作入路.也同時在前側(cè)建立一個小切口來作為錨釘置入的入路.在后側(cè)入路插入關(guān)節(jié)鏡,進(jìn)行觀察.Rotator Cuff肩袖修復(fù)在這個手術(shù)操作過程中以L形肩袖撕裂為例.圖中顯示為岡上肌的L形撕裂Rotator Cuff肩袖修復(fù)ELITE肩關(guān)節(jié)探勾通過前側(cè)入路來評估撕裂程度.同時可應(yīng)用抓鉗來評估撕裂程度Rotator Cuff肩袖修復(fù)將關(guān)節(jié)鏡鏡頭變換至側(cè)面工作入路.使用直型的ELITE CUFF STITCH縫合傳遞器械在后側(cè)入路內(nèi),穿過撕裂的肩袖組織部位來傳遞縫線.使用縫線組織抓鉗通過前側(cè)入路抓取縫線.Rotator Cuff肩袖修復(fù)移去直型的ELITE CUFF STITCH縫合傳遞器械在后側(cè)入路插入ELITE縫線抓鉗,從前側(cè)入路處重新抓取縫線.Rotator Cuff肩袖修復(fù)將2股縫線移入同一個入路,移去縫線抓鉗在后側(cè)入路外打一個關(guān)節(jié)鏡下滑節(jié).通過后側(cè)入路將結(jié)移向撕裂處使用ELITE全圈推結(jié)器對滑結(jié)推向撕裂處Rotator Cuff肩袖修復(fù)通過全圈推結(jié)器的配合操作,對滑節(jié)進(jìn)