肩袖损伤PPT参考幻灯片

肩袖损伤的关节镜治疗,戴永立蚌埠三院骨科E-mail:ahmudly,1,概念和功能,由冈上肌、冈下肌、肩胛下肌及小圆肌之肌腱在肱骨头前、上、后方形成的袖套样肌样结构。在任何运动或静止状态保持肱盂关节稳定，并使之成为运动的轴心和支点维持上臂各种姿势和完成各种运动功能。,2,4,1,3,2,5,肩胛骨,3.喙突4.肱骨头5.关节盂,1.锁骨2.肩峰,肩关节解剖之骨骼,3,4,1,3,2,5,肩胛骨,3.喙突4.肱骨头5.关节盂,1.锁骨2.肩峰,肩关节骨骼,4,肩袖解剖,5,肩袖解剖,6,组成和功能,冈上肌(肩胛上神经):上臂外展并固定肱骨头于肩盂上并防止肱骨头上移,冈下肌(肩胛上神经):上臂下垂位时使上臂外旋,小圆肌(腋神经):臂外旋,肩胛下肌(肩胛下神经):臂下垂位时内旋肩关节,7,病因,退变学说血运学说撞击学说创伤学说,冈上肌止点附近血供来源于大结节骨膜滋养血管，肌腹血供来源于肩胛上动脉，而止点近端1cm处有明显的乏血管区,肩峰发育异常、肩锁关节增生肥大、高位肱骨大结节、肩峰下骨赘形成肩峰下撞击综合征,8,分类,按损伤程度：挫伤不完全断裂完全断裂,9,分类,按断裂口方向横行纵行,按肌腱断裂范围小型撕裂：单一肌腱撕裂范围小于肌腱横径1/2大型撕裂：单一肌腱撕裂范围大于肌腱横径1/2广泛撕裂：范围累及两个及两个以上的肩袖肌腱，伴有肩袖组织的退缩缺损,10,临床表现,11,临床表现,外伤史：急性损伤、重复性或累积性损伤史疼痛与压痛：多位于肩前方活动或增加负荷后加重被动外旋或过度内收时加重夜间症状加重功能障碍：上举和外展功能受限肌肉萎缩：3周继发性关节挛缩：3月,12,当我们在临床上遇到疑似病人，只有X片而无MRI检查时，1我们能从X片中得到什么信息？2我们印象中的可疑诊断有哪些？3针对性的体查有哪些？,13,GazzolaS,BleakneyRR.CurrentimagingoftherotatorcuffJ.SportsMedArthrosc,2011,19(3):300-9.,cysticchangeofthegreatertuberosity,1读X片,14,GazzolaS,BleakneyRR.CurrentimagingoftherotatorcuffJ.SportsMedArthrosc,2011,19(3):300-9.,normalsubacromialjointspace(7mm)(arrow),1superiorsubluxationofthehumeralhead(arrow)2notchedhumeralneck(arrowhead),15,TypeIcalcicationwithauffy,eecyappearancewithpoorlydenedborders,withacutesymptomsandtermedtheresorptivephase.TypeIIcalcication,morediscreetandofhomogenousdensity,withwell-circumscribedborders,andintheformativephase.,DePalmaAF,KruperJS.Long-termstudyofshoulderjointsaffliatedwithandtreatedforcalcictendinitisJ.ClinOrthop.1961;20:61-72.,calcictendinopathy,16,2可疑诊断,1关于肩周炎肩周炎=冻结肩（实用骨科学第3版），是由于肩关节周围软组织病变而引起肩关节疼痛和活动功能障碍。国外报道Frozenshoulder40-60yearsofage,incidence2-5%1.3phases2freezingphase2-9months,painandlossofmotionoftheglenohumeraljointinalldirection，usuallyworstatnightandwhenlyingontheaffectedside2)frozenphase4-12months,stiffnessreachesitsmaximumthawingphase5-12months,rangeofmotionreturnstonormal2肩峰下撞击综合症疼痛，主诉为三角肌下疼痛，并经常向下放射至前方的肱二头肌，夜间疼痛可影响睡眠,1HandC,ClipshamK,ReesJL,etal.Long-termoutcomeoffrozenshoulder.JShoulderElbowSurg2008;17:231-6.2ReevesB.Thenaturalhistoryofthefrozenshouldersyndrome.ScandJRheumatol1975;4:193-6.,17,针对肩袖损伤的体查,1冈上肌肩外展功能,1emptycantest1)90degreesabduction2)30degreeshorizontalabduction(intheplaneofthescapula)3)thumbspointingdownward,18,2fullcantest1)90degreesinthehorizontalplane2)rotated45degreesexternally3)withthethumbpointingupward,19,painfularctest60-1201)shoulderinexternalrotation2)palmfacingup,20,4resistedisometricabduction1)thearminneutralrotation2)abductsthearmto90degrees,21,1externalrotationstrengthtest=Pattestest1)thepatientselbowin90degrees2)intheplaneofthescapula,2冈下肌和小圆肌肩外旋功能,22,2externalrotationlagsign1)elbowpassivelyflexedto90degrees2)maximalexternalrotation,23,3dropsign1)almostfullexternalrotation2)elbowflexedat90degrees,24,4weaknesswithexternalrotation1)elbowsflexedto90degrees2)thethumbsup3)shouldersrotatedinternally20degrees,25,3肩胛下肌肩内旋、后伸功能,1liftofftestaskingthepatienttointernallyrotatethearmtoliftthehandposteriorlyoffoftheback,26,2internalrotationlagsign,27,3bellypress,28,4bearhugtest,29,4针对肩峰下撞击综合症的体查,30,Hawkins-Kennedytest,31,关于MRI,肩袖解剖,32,解剖足印（footprint）,33,关于MRI,正常肩袖的MRI斜冠状面,34,正常肩袖的MRI斜矢状面,35,正常肩袖的MRI横断面,36,损伤肩袖的MRI,37,魔法角magicanglephenomenonthefibersareat55degreestothemainmagneticfieldonT1EricksonSJ,ProstRW,TiminsME.The“magicangle”effect:backgroundphysicsandclinicalrelevance.Radiology.1993;188:23-25.,38,MRI上应得到的信息,1肩袖走行及连续性2高信号3脂肪变性4肌肉萎缩5肌肉回缩6三角肌下、肩峰下囊滑液相连,39,肩袖走行及连续性,40,脂肪渗透（fattyinfiltration）,FuchsB,WeishauptD,ZanettiM,HodlerJ,GerberC.Fattydegenerationofthemusclesoftherotatorcuff:assessmentbycomputedtomographyversusmagneticresonanceimaging.JShoulderElbowSurg1999;8:599-605.,41,肌肉萎缩（muscleatrophy）,1切线征1（tangentsign）2肩胛比（scapularratio）Scapularratiousestheratioofthesupraspinatusmuscleincrosssectiononthesagittalobliqueimagecomparedwiththesizeofthesupraspinatusfossa,andinsupraspinatusatrophytheratioislessthan50%2.,1ZanettiM,GerberC,HodlerJ.Quantitativeassessmentofthemusclesoftherotatorcuffwithmagneticresonanceimaging.InvestRadiol.1998;33:163-170.2ThomazeauH,RollandY,LucasC,etal.Atrophyofthesupraspinatusbelly.AssessmentbyMRIin55patientswithrotatorcuffpathology.ActaOrthopScand.1996;67:264-268.,42,43,肩袖损伤的分类,1全层撕裂1）小1cm2）中1-3cm3）大3-5cm4）巨大5cm,DeOrioJK,CoeldRH.Resultsofasecondattemptatsurgicalrepairofafailedinitialrotator-cuffrepair.JBoneJointSurg.1984;66:563567.,44,肩袖损伤的分类,2部分撕裂,45,肩袖损伤的治疗,手术VS保守parametersindecisionmakingforthesurgeryofthecuff1.75years2撕裂大小Shimizu2recommendearlycuffrepairafterconrmingthediagnosisofmassiverotatorcufftears.Partial-thicknessrotatorcufftearisafurtherindicationinthosepatientswithminimalriskoftearextension,minimalpain,anddysfunction3.,1TanakaM,ItoiE,SatoK,etal.Factorsrelatedtosuccessfuloutcomeofconservativetreatmentforrotatorcufftears.UpsJMedSci.2010;115:193-200.2ShimizuC,HoriiM,YamashitaF,etal.Prognosisofmassiverotatorcufftear.Chubuseisai.1990;33:392.3OzbaydarMU,BekmezciT,TonbulM,etal.Theresultsofarthroscopicrepairinpartialrotatorcufftears.ActaOrthopTraumatolTurc.2006;40:4955.,46,肩袖损伤的治疗,肌腱的缝法,47,开放手术骨质端的固定,48,肩袖损伤的治疗,手术方式的选择开放手术VS关节镜手术美国的一篇系统评价显示：术后6个月的ASES、UCLA、疼痛评分及再断裂方面，两者无显著差异，只有短期疼痛，关节镜优于开放手术。,LindleyK,JonesGL.Outcomesofarthroscopicversusopenrotatorcuffrepair:asystematicreviewoftheliterature.AmJOrthop(BelleMeadNJ),2010,39(12):592-600.,49,不可修复肩袖损伤的判定,AccordingtoGerberetal.,imagingndingsthatsuggestanirreparablerotatorcufftearinclude1）staticsuperiorsubluxationofaglenohumeraljointwithanacromiohumeralintervalof7mmorlessonananteroposteriorradiographwiththearminneutralrotation,GerberC,WirthSH,FarshadM(2011)Treatmentoptionsformassiverotatorcufftears.JShouldElbSurg20:S20S29.,50,and2)fattyinltrationoftherotatorcuffmusclesatstagethreeorgreater.,51,不可修复肩袖损伤的治疗,1肱三头肌长头截断2debridementassociatedwithacromioplastyandbursectomy3partialrepair4arthroscopictuberoplasty5tendontransfers1)latissimusdorsitransfers-superolateralrotatorcufftears2)pectoralismajortransfers-irreparabletearsofthesubscapularismuscle3)deltoidap4)trapeziusmuscletransfer,52,latissimusdorsitransfers一篇关于背阔肌修复巨大撕裂肩袖损伤的系统评价结果显示：在45.5个月的随访期内，Constantscore,activeforwardelevation和activeexternalrotation术后明显优于术前。,NamdariS,VoletiP,BaldwinK,GlaserD,HuffmanGR.Latissimusdorsitendontransferforirreparablerotatorcufftears:asystematicreview.JBoneJointSurgAm,2012,94(10):891-8.,53,RotatorCuff肩袖损伤,撞击通常在老年患者(65+)勾状的肩峰和肩袖撞击导致疼痛和附加的肩袖撕裂肩袖损伤通常地这种情况导致冈上肌损伤,然后是冈下肌很少情况下会损伤小圆肌除非在极其严重的情况下,肩胛下肌损伤极其少见,处理也很困难部分撕裂也非常常见,这种情况也是治疗的人选,54,RotatorCuff肩袖损伤,四种主要的肩袖撕裂类型：1）新月形撕裂2）U形撕裂3）L形和倒L形撕裂4）巨大回缩性不可移动性撕裂,55,RotatorCuff肩袖损伤,新月形撕裂IS冈下肌SS冈上肌,56,RotatorCuff肩袖损伤,U形撕裂IS冈下肌SS冈上肌,57,RotatorCuff肩袖损伤,L形撕裂IS冈下肌Sub肩胛下肌肌腱RI肩袖间隙SS冈上肌CHL喙肱韧带,58,RotatorCuff肩袖损伤,巨大回缩性不可移动性撕裂IS冈下肌Sub肩胛下肌肌腱RI肩袖间隙SS冈上肌CHL喙肱韧带,59,前面,侧面/后面,肩峰下囊是个潜在的空间直到充满了流体在关节镜手术中,肩峰下囊,60,前面观,侧面/后面观,肩袖由四块肌肉和他们的肌腱组成,1.,2,3,4,1.肩胛下肌,2.冈上肌,肩袖,3.冈下肌,4.小圆肌,61,肩袖关节镜下观,RotatorCuff,HumeralHead,62,RotatorCuff肩袖损伤,肱骨头,肩袖,肱骨头,肩袖,关节囊方向看,肱骨头方向看,63,RotatorCuff肩袖损伤,撞击通常在老年患者(65+)勾状的肩峰和肩袖撞击导致疼痛和附加的肩袖撕裂肩袖损伤通常地这种情况导致冈上肌损伤,然后是冈下肌很少情况下会损伤小圆肌除非在极其严重的情况下,肩胛下肌损伤极其少见,处理也很困难部分撕裂也非常常见,这种情况也是治疗的人选,64,RotatorCuff肩袖损伤,四种主要的肩袖撕裂类型：1）新月形撕裂2）U形撕裂3）L形和倒L形撕裂4）巨大回缩性不可移动性撕裂,65,RotatorCuff肩袖损伤,新月形撕裂IS冈下肌SS冈上肌,66,RotatorCuff肩袖修补,67,RotatorCuff肩袖修复主要考虑因素,主要目标减少活动疼痛(SAD)和恢复运动功能入路锚钉放置过线.打结,68,RotatorCuff肩袖修复方式,穿骨缝线,带线铆钉,69,选择锚钉,肩袖损伤:TwinFixTi5.0mm:骨质疏松，需要高固定强度.多个缝线肩关节不稳(BankartandSLAP)TwinFixTi3.5mm:此锚钉可以用于所有手术，包括肩袖损伤肩关节不稳(BankartandSLAP)TwinFixTi2.8mm:关节盂表面较小，医生需选择较小的锚钉，但是也需要很高的拔出强度.选择使用单线孔锚钉，对于缝线的操作比较简单肩袖损伤及肩关节不稳TwinFixTiSutureAnchorRangewithNeedles如医生进行开放手术，选择带针的缝线锚钉.,70,RotatorCuff肩袖修复,应用3个入路在这个手术过程中-后侧,前侧,侧面的工作入路.也同时在前侧建立一个小切口来作为锚钉置入的入路.在后侧入路插入关节镜,进行观察.,71,RotatorCuff肩袖修复,在这个手术操作过程中以L形肩袖撕裂为例.图中显示为冈上肌的L形撕裂,72,RotatorCuff肩袖修复,ELITE肩关节探勾通过前侧入路来评估撕裂程度.同时可应用抓钳来评估撕裂程度,73,RotatorCuff肩袖修复,将关节镜镜头变换至侧面工作入路.使用直型的ELITECUFFSTITCH缝合传递器械在后侧入路内,穿过撕裂的肩袖组织部位来传递缝线.使用缝线组织抓钳通过前侧入路抓取缝线.,74,RotatorCuff肩袖修复,移去直型的ELITECUFFSTITCH缝合传递器械在后侧入路插入ELITE缝线抓钳,从前侧入路处重新抓取缝线.,75,RotatorCuff肩袖修复,将2股缝线移入同一个入路,移去缝线抓钳在后侧入路外打一个关节镜下滑节.通过后侧入路将结移向撕裂处使用ELITE全圈推结器对滑结推向撕裂处,76,RotatorCuff肩袖修复,通过全圈推结器的配合操作,对滑节进行打紧.,77,RotatorCuff肩袖修复,用ELITE勾型剪剪断缝线可以使用滑动剪线器进行代替使用,78,RotatorCuff肩袖修复,缝线传递的另外方法用直型缝线传递器械夹带缝线通过后侧入路穿透肩袖,AP抓钳通过前侧入路穿透肩袖,配合操作,将缝线穿