肩袖撕裂的治疗

吴煌宜昌市第二人民医院三峡大学附属第二人民医院宜昌市中西医结合医院ManagementofRotatorCuffTears肩袖撕裂的治疗

---从基础到手术ShoulderAnatomy肩关节解剖RotatorCuff肩袖Supraspinatusfootprint冈上肌足印--A-P:25mm前后向：25mm--M-L:12.1-12.7mm内外向：12.1-12.7mm--1-1.7mmfromartmargin距离软骨缘1-1.7mm

Dugas,JSES2002;Ruotolo,Arthroscopy20045histologiclayers5层组织学结构--1（supf）largearterioles丰富的动脉网--2largebundlesoftendonfibers粗大的肌腱纤维--3smallercollagenbuneles小的胶原纤维素--4looseCT疏松的结缔组织--5shouldercapsule肩关节囊

Clark,JBJS1992Supra-andInfra-spinatousFootprints冈上肌和冈下肌的足印A-commonlyacceptedmodel普遍认同的足印分布B-Mochizukietal,JBJS2008

Mochizuki2008年发表于JBJS的研究结果SubscapularisFootprint肩胛下肌足印RichardsetalArthoscopyA=39.5mmB=16.0mmIdeetal.Arthoscopy2008Vascularity血供SupraspinatushypovascularBiomechanics生物力学FunctiontoBalanceForcesCouples(keephumeralheadcentered)力偶平衡（维持肱骨头于旋转中心）-CoronalPlane:Deltoidvsinferiorcuff冠状面：三角肌和下方肩袖ForceCoupling力偶Thedepressoreffectbythesupraspinatusholdstheheadintheglenoidfossaduringelevationofthearm上臂外展冈上肌下压肱骨头将其维持于肩盂内

Withlossofthesupraspinatusthedeltoidsuperiorlydisplacestheheadundertheacromion冈上肌失能后肱骨头上移三角肌通过肩峰支点发挥上抬作用ShoulderAnatomy肩关节解剖RotatorCuff肩袖Supraspinatussitsinaveryprecariousposition

冈上肌的解剖AcromialMorphology

肩峰形态LinkedtoImpingementandMostcommonRotatorCuffTears

撞击是导致肩袖撕裂最常见的原因

RotatorCuffTear肩袖撕裂Atearintherotatorcuffmayresultsuddenlyfromasingletraumaticeventordevelopgraduallybecauseofrepetitiveoverheadactivities

肩袖撕裂可由单次外伤或反复的过顶活动所导致Presistentimpingementmayeventuallyleadtoacufftear

持续的撞击可最终导致肩袖撕裂Commoninages>40years

常见于40岁以上人群RotatorCuffTear肩袖撕裂RotatorCuffTearTreatmnet肩袖撕裂的治疗Dowereallyknowwhatworksbest?

我们是否真的了解哪种方法是最有效的？Wethinkweknowwhatworksbest?

我们自己认为我们已经知道哪些是最佳方法？Whydowedowhatwedo?

我们为什么要采用这些治疗方法？Whatisthecurrentdogmaonrotatorcuffteartreatment?目前肩袖损伤治疗的理念？

RepairTheCuff!修复肩袖！WhyDogma信条/准则

HowMedicinewasPracticedfromHippocratesuntilnow自希波克拉底以来的医学实践与进步Apprenticeship导师制WhydoIpracticethewayIdo?为什么我这么做？-BecauseWarrendidit...-BecauseNeerdidit...-BecauseCodmandidit...

Bloodletting放血疗法Oneofthemostenduringandpopularmedicalpracticesinhistory.

历史上最为广泛开展的治疗方法之一OriginatedbyGreeksuseduntil19thcentury

源于希腊FourHumours:Blood,Phlegm,YellowBile,BlackBilegetoutofbalance

四种体液的平衡：血液、痰液、黄胆汁、黑胆汁ContributedtoDeathofGeorgeWashington

导致了乔治华盛顿的死亡EvidenceBasedMedicine循证医学WeneedtouseDATA,notDOGMA我们需要数据，而非信条Questionthethingswedoandfinddatatosupportourpracticepatterns质疑我们目前的做法，寻找支持现有治疗方法的证据CaseScenario

病例70yearsfemalewithPainfulLeftShoulder,6months70岁左肩痛女性,6月-Nohistoryofinjury无外伤史-Nightpain夜间痛-Crepitus弹响-Limitshouseworking,exercise家务活和锻炼受限-ExamFullPainfulROM全活动范围均疼痛-MRIWhatwouldyoudoandwhy?你会怎么做以及原因？Howmanywould:有多少人会想：-OfferSurgery?手术治疗？-OfferPhysicalTherapy?物理治疗？-OfferInjection?关节腔注射？Istheredataonthebestapproach?

有数据能告诉我们哪种治疗方法最好？Isthereaconsensusonthebestapproach?

有共识吗？SystematicReviews系统回顾IndicationsforSurgery手术指征86PapersReviewed回顾了86篇文献PatientsCharacteristicsandIndicationsnotdescribedinmost

大多数文献均未明确患者基本资料和手术指征-LimitationsinADL(31%)日常活动受限（31%）-FailureofNonoperativeTx(52%)非手术治疗无效（52%）-DurationofNonoperativeTx(26%)手术治疗（26%）-NightPain(16%)夜间痛（16%）SystematicReviews系统回顾IndicationsforSurgery手术指征LevelⅢReview证据等级Ⅲ级的综述研究Resultsthatwerehelpful对临床有指导意义的结论-Acutetearsmaybenefitfromearlysurgery急性撕裂早期手术效果好-WeaknessorFunctionalDisabilitymayhaveworseoutcomeswithnonoperativetreatment非手术治疗会导致力弱和功能障碍

TheBestEvidenceSuggests目前最佳的临床证据提示AcuteTearsshouldbeRepaired急性撕裂应当手术修复WeaknessisanIndicationforRotatorCuffRepair力弱是肩袖修复手术的指征Question问题Whatisthebestwaytotreatthepatientwithoutanacutetear：非急性撕裂患者的最佳治疗方法：-Haspain伴有疼痛-HasanMRIwithacufftear核磁提示肩袖撕裂Whataretheindicationsforsurgery?手术指征？Shouldthesepatientsbemanagednon-operatively?应当先采用非手术治疗吗？Isnonoperativetreatmentofcufftearseffective?非手术治疗对于肩袖撕裂有效吗？

2011NeerAwardMulticenterProspectiveCohort多中心队列研究452patientsAvg.age63years平均63岁AtraumaticFullThicknessRotatorCuffTears

非创伤性肩袖全层撕裂TreatedwithEBMPhysicalTherapyProgram

按照循证医学的要求开展物理治疗Followedat6,12weeksand1,2years

分别在治疗后的6，12周和1，2年进行随访Resultdonotseemtoworsenwithtime研究结果提示疗效并不会随之加重PatientOutcomeMeasuresAfterNonoperative非手术治疗后的疗效评估P<0.0001,andclinicallysignificantdifferrencesConclusionsPhysicaltherapyprogramiseffectivenonoperativetreatmentforatraumaticRotatorCuffTears物理治疗是非外伤性肩袖撕裂的有效非手术治疗方法-Outcomescoresimprovedover12weeks

治疗后12周的疗效评分有所改善-<20%ofpatientsfailedandhadsurgery

仅有20%以内的患者治疗失败转为手术-Patientswhochosetohavesurgerygenerallydosointhefirst6-12weeks

最终选择手术的患者大多数都在最初的6-12周内接受了物理治疗-After12weekseffectivenesslasts2years12周后非手术治疗的效果可以持续到2年Non-operativetreatmentisanoption!非手术治疗是一种选择Ifthepatientfailsthistreatmentorifanacutetearortearinyoungerpatient,thensurgery......急性撕裂或年轻患者可以先接受非手术治疗，如果失败再转为手术RotatorCuffSurgery肩袖撕裂的手术治疗RotatorCuffSurgicalIssues手术治疗的相关问题-FactorsinHealing影响愈合的因素-Plateletrichplasma富血小板血浆-OpenvsArthroscopic开放还是镜下-DoubleRowvsSingleRow单排还是双排IfIdon’thavesurgerywhatwillhappentomyrotatorcuff?肩袖撕裂如果不手术会怎么样？Platelet-RichPlasma(PRP)富血小板血浆Fivestudies(2randomized,3un-randomized)5项研究

（2项随机，3项非随机）PRPhadnoeffectonoutcomesorre-tearratesPRP对疗效和再撕裂无影响Arthroscopy2012TheNaturalHistoryofSymptomaticRotatorCuffTears症状性肩袖撕裂的自然史Patientswithcufftearsmaybeatsignificantriskforsizeprogressionovertime

症状性肩袖撕裂患者撕裂程度的进展风险很高39%ofTearsshowedprogression

39%的病例出现撕裂进展Notearsdecreasedinsize

未见撕裂程度减小的病例Directrelationshipwithsymptomsandtearsizeprogression

症状与撕裂程度进展明显相关YamaguchiJSES10:3,2007Progressionofpartialtear部分撕裂的进展40%PTRCTwillprogresstoFTRCTwithin2years40%的部分撕裂会在2年内进展为全层撕裂Piandevelopmentisassociatedwithtearprogression疼痛可能与撕裂进展有关Functiontendstodeterioratewithinc.intearsize,evenwithincreaseintearsize,nofattyatrophy/lossofERstrength功能也和撕裂程度的进展有关，即便肩袖没有脂肪浸润、外旋障碍

Mall.JBJS,2010IfIhaveasurgicalrepairwillmyrotatorcuffheal?手术修补一定能使肩袖愈合吗？TearPattern撕裂类型MethodofRepair修补方法SurgicalSkill手术技巧Ageofpatient

年龄Chronicityoftear撕裂病程RehabilitionProtocol康复策略HealingofChronicTears陈旧性撕裂的愈合Fealy,Warrenetal-50%healingdocumentedviaultrasoundFealy,Warren等通过超声检查发现50%的肩袖会愈合Sugaya,etal-40%healingdocumentedviaMRISugaya等通过核磁研究发现愈合率为40%Gerberetal-87%singletendonand58%forlargetearsdocumentedviaMRIGerber等通过核磁研究发现单根肌腱撕裂和巨大撕裂的愈合率分别为87%和58%Greber,JBJS,2000Brunner,2004FactorsThatInfluenceHealing:SurgicalSkill影响愈合的因素：手术技巧SurgicalSkillandExperienceisamuchmoreimportantfactorthanthemethodofrepair

手术技巧和经验比修补方法更重要AnExpertlyPerformedopencuffrepairservesthepatientbetterthanamediocrearthroscopicrepair

专家切开修复肩袖的效果优于新手进行镜下修补Continuousmedicaleducationandrepetitionareimportant

继续教育和培训非常重要FactorsThatInfluenceHealing:Environmentalfactors影响愈合的因素：生物环境Nicotinedelaystendon-to-bonehealinginananimalmodel

动物实验发现尼古丁导致腱骨愈合时间延长IndomethacinandCelecoxibimpairtendon-to-bonehealinginananimalmodel

动物实验发现吲哚美辛和塞来昔布影响腱骨愈合---Galatzetal.JBJS2006---Cohen,Rodeoetal.AJSM2006Surgicalmethod手术方法FixationStrength固定的强度OpenvsArthroscopic开放还是镜下RestorationoftheFootprint恢复足印区SutureMaterial缝线材质SutureConfiguration缝线构型TripleLoadedvsDoubleloadedanchors三线或双线锚钉FactorsThatInfluenceHealing:BiologyandEnvironment影响愈合的因素：生物学和环境Biology生物学-DegenerativeTissueQuality退变组织的质量-Agerelatedsuppressionofhealingcapacity年龄对愈合能力的影响-Abilityoftendontohealtobone腱骨愈合的能力-GrowthFactors生长因素-Corticosteroidinducedsuppression激素影响愈合Environment环境-Rehabprotocol康复策略（是否佩戴支具）-Smoking吸烟-Anti-inflammatorymedication抗炎药物HealingofRotatorCuff:FactorsThatWeCanControl我们能够控制的影响愈合因素Age-No-Maybe年龄-可能不行

Operativetechnique-Yes手术技术-可以Stageoftear-No-Maybe撕裂程度-可能不行-PartialvsFull部分还是全层-ChronicvsAcute慢性还是急性-LargevsSmall巨大还是小型EnvironmentalFactors环境因素-Smoking-Maybe

吸烟-可能可以-Activitylevel-Yes活动水平-可以

-Rehab-Yes康复-可以-Meds-Yes药物-可以HealingCapacity愈合能力GoodPotentialtoHeal能够愈合-PartialTears部分撕裂-SmallTears小型撕裂-YoungPatients年轻患者MoreLimitedPotentialtoHeal很难愈合-RevisionSurgery翻修手术-LargeTears巨大撕裂-ChronicTears陈旧性撕裂-OlderPatients(>65)高龄患者

（>65）OpenvsArthroscopic开放还是镜下Nosignificantdifferrence无显著差异ArthroscopicAdvantagesDeltoidpreserving不破坏三角肌ROMBetter活动度更好Evaluateglenohumeraljointforassociatedpathology

同时探查盂肱关节病变Cosmetic切口美观Indications指征Partialtears部分撕裂Smalltears(<1cm)小型撕裂(<1cm)Mediumtears(1-3cm)中等撕裂(1-3cm)Largetears(3-5cm)大撕裂(3-5cm)Massivetears(>5cm)巨大撕裂(>5cm)

-Repairable可修复

-Partiallyrepairable部分修复-Irrepairable不可修复TipsforSuccessinRepair成功修复的要点Practice练习Positioning:BeachchairorLateralDecubitus体位:沙滩椅或侧卧位Arthoscopicjointassessment:Biceps,Labrum,Subscapularis,etal镜下探查：长头腱、盂唇、肩胛下肌等Bursectomy-Importantforvisualizationandremovalofpainfulmediators滑囊切除-有助于改善视野并去除疼痛介质Acromioplasty-considerifnecessary,mayneedfortovisualize肩峰成形-去除病因，增加视野Cufftearassessment-shape,mobility,tendonquality,debrideunhealthytissue撕裂评估-形态、张力、肌腱质量、去除质量差的组织Tuberositypreparation:bleedingbone,punctateholeswithawlordrill大结节骨床准备：骨面渗血、钻孔Cuffmobilization:bursalreleases,capsularreleases肩袖松解:滑囊侧松解、关节侧松解SubacromialDecompression肩峰下减压Doesithelpinoutcomes?是否有助于提高临床疗效FourlevelⅠstudies4项Ⅰ等级研究Nodifferenceinfunctionaloutcomeswithorwithoutacromioplasty是否行肩峰成形对疗效无影响Cuffrepair+/-acromioplasty肩袖修补联合或不联合肩峰成形Nodifferenceinshorttermoutcomes短期疗效无差别Higherreoperationrateinnon-acromioplastygroup未行肩峰成形术组再手术率较高MacdonaldP，etal.JBJS,2011Anchorplacement:armposition,spacing,orientationonGT

锚钉植入：外展角度、位置、方向Suturepassage:equipmentoptions-usepasserthatworkbestforyou

过线：选择最适合自己使用的器械Donotovertension避免张力过大DoubleRowvsSingleRow?双排还是单排？SutureManagement缝线管理Finalrepairassessment术后评估PostopSling术后支具Rehabilitation康复TipsforSuccessinRepair成功修复的要点45°angle(90°totendonpull)“Deadman’sangel”与肌腱回缩方向成45°“死人角”“Deadman’sangel”概念来自1995年StephenS.Burkhart提出的理论，指锚钉以45°角植入，此时锚钉受到的应力最小BurkhartSS.Thedeadmantheoryofsutureanchors.Arthroscopy.1995Approx5-8mmbetweenanchorsSuturepassing穿刺过线5-10mmintotendon肌腱边缘向内约5-10mmSinglevsDouble-Row:单排对比双排Basicsciencedemonstratedoublerowrepairhave:双排的理由1)Improvedfailurestrength强化失效张力2)Greaterfootprintcoverage更好的大结节覆盖3)Lessgapformation减少空隙形成Clinicalstudieshaveyettodemonstrateconclusiveevidenceofabenefitinpatientswithtears<3cm临床研究证实<3cm的撕裂双排更好Maybebeneficialintears>3cm大于3cm的撕裂双排可能更好Currentlynotcost-effectivegivenpriceofORtimeandimplants

由于手术时间增加以及内植物增加可能影响其花费效益比Singlerow46%足印附着SutureBridge100%足印附着KimDH,etal.AmJSportsMed,2006,34(3),407-414.RehabilitationCritical康复非常重要Slingwithsmallpillow

使用小的外展枕进行悬吊Passivemotionfor6weeks6周被动活动AAROM/AROMafter6weeks6周后开始主动活动Strengthening,armatside10weeks

术后10周强化体侧力量训练Strengtheningoverhead>12-14weeks12-14周后强化过顶运动PrinciplesofHealing愈合的原则Debridetovasculartissue清创至组织渗血Debridetorawbone完全清除骨面的组织Tension-freerepair无张力修补TearPattern撕裂的类型Mclaughlin,JBJS,1951PartialRotatorCuffTears肩袖部分撕裂

ApproachtothePartialCuffTear治疗方法Norepair不修补1.NoSurgery不手术2.SurgicalDecompress/Debride肩峰下减压/清创Repair修补1.Completethetearandthenfix转为全层撕裂进行修补2.PASTArepairPASTA损伤的修补Majorityofresearchbasedonimpingement&FTRCT大部分研究基于撞击理论和全层撕裂

-Subacromialimpingement肩峰下撞击-Shouldinstability肩不稳-Repetitivemicrotrauma反复微小损伤PartialCuffTear-SAD/Debride部分撕裂-肩峰下减压/清理16articles16篇文献7articles:debridement/SAD7篇：清理/肩峰下减压9articles:Repair9篇：修补Concluded:结论-<50%partialcufftearstreatwithdebridement+/-SAD<50%的部分撕裂采用清理+/-肩峰下减压治疗->50%partialcufftears:cuffrepair>50%的部分撕裂：肩袖修补PartialTear:Completeit!部分撕裂：转为全层HavesuspicionfromMRI基于MRI的考量-Doesthetendonhaveadegenerativesignal？肌腱是否存在退变表现-Howmuchtendonisinvolved?肌腱受累范围多大？PartialTear:Completeit!部分撕裂：转为全层Debridethearticularside清理关节侧Measureexposedfootprint测量裸露的足印区-Canuesshaverdiameter可以使用刨刀进行测量Markwithsuture使用缝线进行标记Subacromialbursectomy

肩峰下滑囊切除Evaluate&debridebursaltendon评估并清理滑囊侧肌腱Usebluntprobeonthetissue使用探勾评估组织质量Old,degenerativetear>50%oftotalarticularsidefootprintexposed高龄，退变撕裂累及50%以上肌腱，关节侧足印区裸露BrightsignalevidentonMRIindicatingdegenerativetissueandoftenintratendinoustearingMRI高信号提示肩袖退变并经常表现为肌腱内撕裂-Possibilitythatthistissueispartofthepaingeneratorandneedstoberemoved

退变组织可能是疼痛的来源，需要去除Why50%?为什么选择50%这个阈值？Stressinresidualtendonincreasesinanon-linearfashionintears>50%50%以上的部分撕裂会增大残留肌腱的应力Yangetal,JournalofShoulderandElbowSurgery2009(18),379-385.PartialTear:Completeit!部分撕裂：转为全层Outcomes疗效Shinetal,Arthroscopy2012-N=48,Prospective,randomized48例前瞻性随机研究-Morestiffnessintrans-tendonrepair穿肌腱修复组黏连更多-2failureoftakedownbyMRI经MRI证实的转全层修复失败2例

Bollier,etal,LowaOrthopJ2012-Systematicreview系统回顾-14studies14项研究-Improvedoutcomesanddec.morbiditywithatakedown

采用转为全层进行修补疗效更好，并发症更少

PASTArepairConsiderthistranstendonrepairwithgoodtissueandpartialtearof30-60%建议将穿肌腱修补技术用于累及30-60%的关节侧撕裂，且组织质量良好OstiLeonardoetal.Transtendonrepairinpartialarticularsupraspinatustendontear,BritishMedicalBulletin,2017.Arthroscopicrepairofthesubscapularis肩胛下肌的镜下修补Indications

指征-Partialorfull-thicknesstears部分或全层撕裂-Foracutetearsinallagegroups所有的急性撕裂

-Forchronictearsages<65yearsold65岁以下的陈旧撕裂Goals目标

-Repairsubscapulariswithsutures/anchors使用带线锚钉修补肩胛下肌-RestorenativeglenohumeralkinematicsandROM恢复盂肱关节生物力学和活动度-Balancetheforcecouplesaboutthejoint,keepthehumeralheadcentered

恢复力偶平衡，维持肱骨头旋转中心-Increasestrength增强上肢力量-Decreasepain减少疼痛ArthroscopicSubscapularisRepairTechnique镜下肩胛下肌修补的手术技术Beach-chairorlateraldecubitus

沙滩椅位或侧卧位Preferbeachchairforanatomicviewing

个人喜好沙滩椅位因为视野更解剖Abletomovethearmeasilyandadjusttheareaofthelessertuberosityforanchorplacementandsuturetying

容易控制上肢位置以显露小结节置钉和过线打结Portals入路Anterosuperolateral前上入路(B)-Primaryworkingportal主要的工作通道-Justoffanterolateraltipofacromion肩峰的前外缘-Usefulformobilization,suturepassgae,LTpreparation

用于松解、过线和小结节骨床准备Anterior前方入路(A)-Moremedialthanstand