AOTS:肩袖修复术能够缓解肩袖撕裂后肌肉萎缩和脂肪浸润吗?

2014-07-21 evilwind 丁香园

肩袖全层撕裂后常伴随肩袖肌肉回缩、萎缩、纤维化和脂肪浸润等严重影响肩袖功能的并发症。目前对肩袖全层撕裂后肌肉数量和质量改变受哪些病理病生因素影响尚不清楚,值得进一步研究。肩袖的脂肪浸润程度首先由Goutallier在CT下评估分级,Fuchs以此为基础使用MRI评估分级,肩袖肌肉萎缩程度以MRI下冈上肌的萎缩程度来评估。 肩袖肌肉萎缩程度和脂肪浸润程度是决定肩袖修复后肩袖愈合和恢复正常功

肩袖全层撕裂后常伴随肩袖肌肉回缩、萎缩、纤维化和脂肪浸润等严重影响肩袖功能的并发症。目前对肩袖全层撕裂后肌肉数量和质量改变受哪些病理病生因素影响尚不清楚,值得进一步研究。肩袖的脂肪浸润程度首先由Goutallier在CT下评估分级,Fuchs以此为基础使用MRI评估分级,肩袖肌肉萎缩程度以MRI下冈上肌的萎缩程度来评估。

肩袖肌肉萎缩程度和脂肪浸润程度是决定肩袖修复后肩袖愈合和恢复正常功能的关键因素。目前临床上对于肩袖修复后肌肉萎缩和脂肪浸润是否可逆尚存在争议。因此Gokmen Deniz及其同事进行了该项回顾性研究,以期能够回答“关节镜下修复肩袖损伤后肌肉萎缩和脂肪浸润程度是否有所恢复,哪些因素影响肩袖的愈合和肩关节功能”这两大问题。

研究相关要素包括:1、时间:2008年3月至2010年4月;2、纳入标准:退行性肩袖撕裂患者,在关节镜下行单排铆钉固定术;3、排除标准:急性创伤性肩袖损伤患者,不能遵守术后康复计划患者,既然有同侧肩关节疾患患者以及未完成MRI检查患者;

4、MRI评估:

1肩袖肌肉萎缩程度(Thomazeau分级——冈上肌与冈上窝的比例):

I级:正常/轻度萎缩 OR=1-0.6;

II级:中度萎缩 OR=0.6-0.4;

III级:重度萎缩 OR<0.4。

2脂肪浸润程度(Goutallier分级——脂肪与肌肉的比例)

0级:未见脂肪浸润;

I级:少量脂肪浸润;

II级:<50%脂肪浸润;

III级:50%脂肪浸润;

IV级:>50%脂肪浸润。

5、关节镜评估:

1肩袖损伤范围

0型:肩袖完整;

1A型:可探查的小破口;

1B型:冈上肌完全撕裂;

2型:肩袖完全撕裂累及冈上肌、冈下肌;

3型:肩袖完全撕裂累及冈上肌、冈下肌和肩胛下肌。

2肩袖损伤程度(DeOrio分型)

轻度撕裂:撕裂破口<1 cm;

中度撕裂:撕裂破口1–3 cm;

重度撕裂:撕裂破口3–5 cm;

巨大撕裂:>5 cm。

6、功能评分:Constant肩关节功能评分。

结果发现:102例患者纳入研究,87例患者完成所有随访项目,14.8%失访率。其中67名女性,20名男性,平均年龄62.5±8.3岁,平均随访30.1±5.8月(最少随访24月)。其中65例(74.7 %) 1B型肩袖撕裂、14 (16.1 %)例2型肩袖撕裂和8 (9.2 %)例3型肩袖撕裂。31 (35.6 %)例轻度撕裂,32 (36.8 %)中度撕裂、16 (18.4 %)重度撕裂和8 (9.2 %)例巨大撕裂。

最后随访时,平均Constant肩关节功能评分94.2 ± 8.2,其中66例 (75.9 %) 优秀, 14例 (16.1 %)良好,7 例(8.0 %)一般。

最终随访时,MRI发现肩袖再撕裂26例 (29.9 %),其中24例(92.3 %)肌肉萎缩程度同术前,2 (7.7 %)加重,3例(11.5%)脂肪浸润程度同术前,23例(85.5 %)加重。61例肩袖完整患者中52例 (85.2 %)肌肉萎缩程度同术前,9例(14.8 %)加重;52例 (85.2 %)脂肪浸润程度同术前,9例(14.8 %)加重。所有患者肩袖肌肉萎缩和脂肪浸润较术前无改善。肩袖是否发生再撕裂与肌肉萎缩程度无关,发生肩袖再撕裂患者脂肪浸润程度明显较高。

发生肩袖再撕裂患者Constant肩关节功能评分明显较低(97.4 ± 5.0 VS 86.6 ± 9.3)

肩袖初始撕裂程度和肩袖最终随访时完整性是Constant肩关节功能评分的独立影响因素。

肩袖是否发生再撕裂与患者年龄、撕裂程度以及初始和最终随访时脂肪浸润程度相关。

作者认为:对于退行性肩袖撕裂,即使在关节镜下进行肩袖修复术后获得了解剖上完整的肩袖肌肉,术后两年内肩袖肌肉萎缩程度和脂肪浸润程度难以得到改善,甚至有可能恶化。因此早期诊断和早期治疗可能是改善预后的方法之一。

如果肩袖发生再次撕裂,肌肉萎缩和脂肪浸润会进一步加剧,术后肩袖完整性的恢复与患者年龄、肩袖撕裂程度和术前脂肪浸润程度有关。

原始出处:

Deniz G1, Kose O, Tugay A, Guler F, Turan A.Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate?Arch Orthop Trauma Surg. 2014 Jul;134(7):985-90. doi: 10.1007/s00402-014-2009-5. Epub 2014 May 21.


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    2014-10-07 chendoc252
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