肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定治療老年SLAP損傷患者的療效分析

趙加松 汪國友 曾勝強 暴丁溯 沈驊睿 扶世杰

肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定治療老年SLAP損傷患者的療效分析

趙加松 汪國友 曾勝強 暴丁溯 沈驊睿 扶世杰

目的分析肱二頭肌長頭腱切斷結(jié)節(jié)間溝下固定治療老年上盂唇前后部（superior labral anterior and posterior，SLAP）損傷患者的臨床療效。方法回顧性分析西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院2014年1月至2015年1月行肩關(guān)節(jié)鏡治療的35例Ⅱ、Ⅳ型老年SLAP損傷患者的臨床資料，其中肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定17例（A組），男9例、女8例，年齡51～68歲，平均58.6歲，左側(cè)7例、右側(cè)10例；肱二頭肌長頭腱切斷關(guān)節(jié)內(nèi)固定18例（B組）,男11例、女7例，年齡51～68歲，平均59.8歲，左側(cè)8例、右側(cè)10例。術(shù)后循序漸進行功能康復(fù)鍛煉，采用美國肩肘外科協(xié)會評分（America shoulder and elbow surgeons'form, ASES）和視覺模擬評分（visual analog scale, VAS）評價治療效果。結(jié)果35例患者均獲隨訪，隨訪時間為1年。術(shù)后的ASES評分和 VAS評分較術(shù)前明顯改善，差異均有統(tǒng)計學(xué)意義（P ＜0.05），兩組患者手術(shù)時間差異無統(tǒng)計學(xué)意義（P＞0.05），所有患者均未發(fā)生神經(jīng)損傷、傷口感染等并發(fā)癥。結(jié)論肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定治療老年SLAP損傷患者的臨床療效確切，是一種值得推廣的治療方法。

關(guān)節(jié)鏡； 肱二頭肌長頭腱； 結(jié)節(jié)間溝； 老年； SLAP損傷

隨著人們生活質(zhì)量的不斷提高和全民體育運動的普及，運動損傷人群數(shù)量呈上升趨勢，上盂唇前后部（superior labral anterior and posterior，SLAP）損傷患者也日益增多。隨著肩關(guān)節(jié)鏡微創(chuàng)技術(shù)的不斷發(fā)展及對肩關(guān)節(jié)疾病診斷水平的日益提高，人們逐漸認識到SLAP損傷是導(dǎo)致臨床上肩部功能障礙的重要因素。SLAP損傷多發(fā)生于青年人或特種運動員，其主要癥狀是疼痛，投擲運動過頭動作時加重，有時出現(xiàn)絞鎖、彈響及不穩(wěn)定機械癥狀，不穩(wěn)定的主訴少見。引起SLAP損傷的原因包括肱二頭肌腱受到外力影響，盂肱關(guān)節(jié)不穩(wěn)定等［1］。老年人發(fā)病率較低，多見于退變原因，年齡是影響SLAP損傷修復(fù)術(shù)后臨床效果的重要因素，老年患者仍然可取得良好的手術(shù)療效，然而需要術(shù)前仔細評估患者需求、手術(shù)風(fēng)險及術(shù)后應(yīng)施行有效的康復(fù)理療。肱二頭肌長頭肌腱固定術(shù)或切斷術(shù)是SLAP損傷修復(fù)的一種選擇［2］。西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院骨關(guān)節(jié)科收治的Snyder分型中Ⅱ、Ⅳ型老年SLAP損傷患者35例，療效確切，現(xiàn)報道如下。

資料與方法

一、一般資料

回顧性分析本院2014年1月至2015年1月行肩關(guān)節(jié)鏡治療的35例Ⅱ、Ⅳ型老年SLAP損傷患者的臨床資料，其中肱二頭肌長頭腱結(jié)節(jié)間溝下關(guān)節(jié)外鉆孔固定17例（A組），男9例、女8例，年齡51～68歲，平均58.6歲，左側(cè)7例、右側(cè)10例；肱二頭肌長頭腱切斷關(guān)節(jié)內(nèi)固定18例（B組），男11例、女7例，年齡51～68歲，平均59.8歲，左側(cè)8例、右側(cè)10例。術(shù)前通過病史詢問、查體和MRI檢查確定肩關(guān)節(jié)盂唇損傷的診斷。術(shù)前完善相關(guān)檢查，充分術(shù)前準(zhǔn)備，無絕對手術(shù)及麻醉禁忌。

二、納入標(biāo)準(zhǔn)

（1）年齡＞50歲；（2）患肩出現(xiàn)彈響、機械性絞鎖等癥狀，持續(xù)3～6個月且康復(fù)鍛煉無效者；（3）正規(guī)保守治療6～8個月無效者；（4）伴肩關(guān)節(jié)不穩(wěn)者。

三、排除標(biāo)準(zhǔn)

（1）肩關(guān)節(jié)習(xí)慣性脫位患者；（2）肩峰下滑囊炎引起的肩峰下壓痛患者；（3）肩關(guān)節(jié)有開放性傷口或者感染的患者；（4）合并有其他部位的損傷，暫時無法行手術(shù)治療的患者；（5）患有其他慢性疾病、傳染病等不宜行手術(shù)治療的患者。

四、手術(shù)方法

全身麻醉后，術(shù)中取沙灘椅位，常規(guī)消毒鋪巾，鋪防水中單，取肩關(guān)節(jié)前外側(cè)和后、前側(cè)手術(shù)入路進行關(guān)節(jié)鏡檢查。術(shù)中首先對盂肱關(guān)節(jié)內(nèi)結(jié)構(gòu)進行探查，明確盂唇損傷類型為Ⅱ、Ⅳ型SLAP損傷，同時探查是否有其他病變，如滑膜增生、關(guān)節(jié)內(nèi)游離體、關(guān)節(jié)囊松弛及肩盂骨質(zhì)缺損等，視情況行相應(yīng)處理。如可先處理增生滑膜、取出游離體等，用刨削刀或磨鉆處理創(chuàng)面或去骨皮質(zhì)，得到出血或新鮮的骨創(chuàng)面以利于盂唇的重新附著后的愈合。根據(jù)術(shù)中盂唇清創(chuàng)情況，于SLAP損傷處行或不行錨釘固定修復(fù)，再于關(guān)節(jié)鏡下切斷肱二頭肌長頭腱，予以關(guān)節(jié)內(nèi)固定或小切口關(guān)節(jié)外結(jié)節(jié)間溝處鉆孔固定（圖1～5），大量生理鹽水沖洗，防止血漿引流管，縫合切口，術(shù)畢。手術(shù)前后常規(guī)拍攝X線片（圖6、7）。

五、術(shù)后處理

術(shù)后予以抗感染、止痛及間斷冰敷處理，肩部予以肩關(guān)節(jié)支具外展制動，術(shù)后第2天拔出血漿引流管。遵循循序漸進過程，術(shù)后2周內(nèi)行握拳、主被動屈肘活動，逐漸行患肩的被動前屈、外展及背伸活動，3周后逐漸行患肩無痛性主動前屈、外展及背伸活動，6周后開始行患肩無痛全范圍活動。術(shù)后3個月進行肌力訓(xùn)練，術(shù)后6個月恢復(fù)原運動水平。

六、療效評定標(biāo)準(zhǔn)

術(shù)前、術(shù)后根據(jù)美國肩肘外科醫(yī)師評分（America shoulder and elbow surgeons'form，ASES）［3］及 視覺模擬評分（visual analog scale，VAS）評估患者肩關(guān)節(jié)功能和疼痛情況。ASES評分滿分為100分，其中疼痛占36%，穩(wěn)定占36%，功能占28%，分數(shù)越高代表肩關(guān)節(jié)功能越好。VAS評分滿分為10分，0分:無痛；3分以下:有輕微的疼痛，能忍受；4～6分:患者疼痛并影響睡眠，尚能忍受；7～10分：患者有漸強烈的疼痛，疼痛難忍，影響食欲，影響睡眠。

七、統(tǒng)計學(xué)分析

應(yīng)用SPSS17.0統(tǒng)計軟件進行數(shù)據(jù)分析，計量資料以 x-±s表示，采用t檢驗，P ＜0.05為差異有統(tǒng)計學(xué)意義。

結(jié) 果

所有患者均獲隨訪，隨訪時間為1年。術(shù)后的ASES評分和VAS評分較術(shù)前明顯改善（表1），術(shù)前和術(shù)后肩關(guān)節(jié)功能ASES評分及VAS評分，差異均有統(tǒng)計學(xué)意義（P ＜0.05），兩組患者手術(shù)時間差異無統(tǒng)計學(xué)意義（P＞0.05），所有患者均未發(fā)生神經(jīng)損傷、傷口感染等并發(fā)癥。

圖1 關(guān)節(jié)鏡下切斷肱二頭肌長頭腱后，關(guān)節(jié)外結(jié)節(jié)間溝下拉出肱二頭肌長頭腱

圖2 編制縫合肱二頭肌長頭腱，于結(jié)節(jié)間溝下鉆孔

圖3 引線穿過鉆孔后加強縫合固定

圖4 結(jié)節(jié)間溝下鉆孔引線示意圖

圖5 加強縫合固定示意圖

圖6 術(shù)前X線片

圖7 術(shù)后X線片

表1 兩組患者手術(shù)前后ASES 、VAS評分及手術(shù)時間比較（±s）

表1 兩組患者手術(shù)前后ASES 、VAS評分及手術(shù)時間比較（±s）

注：與術(shù)前相比，aP＜0.05；AESE為美國肩肘外科協(xié)會評分；VAS為視覺模擬評分

組別 例數(shù) AESE評分（分） VAS評分（分） 手術(shù)時間（min）術(shù)前 術(shù)后 術(shù)前 術(shù)后A 組 17 45.8±7.2 86.5±5.4a 5.3±1.3 3.8±1.5 97.0±18.7 B 組 18 48.4±9.1 86.4±6.0 5.4±1.5 3.1±1.2a 96.1±18.5 t值 25.27 17.67 9.62 11.37 -5.12 P值 ＜0.001 ＜0.001 ＜0.001 ＜0.001 0.62

討 論

SLAP損傷的主要癥狀是疼痛，投擲運動過頭動作時加重，有時出現(xiàn)絞鎖、彈響及不穩(wěn)定機械癥狀，不穩(wěn)定的主訴少見。隨著人們生活水平的提高，老年SLAP損傷患者日益增多。在川南地區(qū)患病率較高，其受傷機制包括高處墜落或直接打擊時；損傷時上肢處于外展前屈時；上肢牽引時；反復(fù)過度過頭運動時，如羽毛球、游泳、籃球、投擲運動等。一些急性損傷也可造成SLAP損傷，例如，對上肢突然牽拉或打擊而使肘關(guān)節(jié)從屈曲位強力伸展可造成急性SLAP損傷。另外，肩關(guān)節(jié)外展及輕度前屈位、肘關(guān)節(jié)伸直時突然摔倒著地，肱骨頭向上方直接撞擊和擠壓盂唇也可造成SLAP損傷。1990年Waldherr等［3］和 Snyder等［4］將 SLAP 損傷分為四種類型，I型：盂唇上部外觀呈磨損和退行性變；Ⅱ型：盂唇上部自其止點分離，沿著二頭肌腱離開盂頸下方（盂唇復(fù)合體不穩(wěn)定）；Ⅲ型：盂唇上部有桶柄狀裂，二頭肌腱完整；Ⅳ型：盂唇上部有桶柄狀裂并延伸到二頭肌腱內(nèi)形成不同程度的劈裂。

對于SLAP損傷的診斷較為困難，有患者自訴肩關(guān)節(jié)活動或處于某些體位時（多為外展外旋位）疼痛，或伴隨關(guān)節(jié)內(nèi)的交鎖、彈響，或不能完成某些動作，如投擲時的“上肢沉墜感”等。但總的來說，病史對盂唇損傷的診斷是非特異性的。除此之外，肩關(guān)節(jié)的體格檢查對盂唇損傷的診斷也非常重要?；匦龜D壓試驗和O'Brien試驗陽性對于SLAP損傷的診斷具有很高的敏感性。對盂唇損傷導(dǎo)致的肩關(guān)節(jié)不穩(wěn)，在全身麻醉下可行多方向抽屈試驗并與健側(cè)對比，其特異性和敏感性比較高。MRI檢查對于肩關(guān)節(jié)軟組織損傷的診斷十分有用，特別是肩袖、肱二頭肌腱及周圍軟組織，但對盂唇和關(guān)節(jié)囊進行充分評估常感困難。因此需要MR關(guān)節(jié)造影術(shù)，對盂唇損傷的敏感度為89%，特異度為91%，精確度為90%［5］。王玉理等［6］回顧性收集35例SLAP損傷患者已行肩關(guān)節(jié)MR造影和關(guān)節(jié)鏡檢查，由2名醫(yī)師觀察分析，通過對照比較，評價肩關(guān)節(jié)MR造影的靈敏度、特異度和準(zhǔn)確度分別是94%、96%和90%。在病程較長的老年肩痛的患者中，當(dāng)癥狀與常見的肩痛病因不一致時，要考慮盂唇損傷，大多盂唇損傷僅能通過肩關(guān)節(jié)鏡明確診斷。肩關(guān)節(jié)鏡檢查才是診斷SLAP損傷的“金標(biāo)準(zhǔn)”［7］。

目前，根據(jù)患者的年齡、活動水平及殘余肱二頭肌條件的不同，SLAP損傷的治療方法也有所不同［8］，該損傷以Ⅱ型最常見［9］，隨著關(guān)節(jié)鏡技術(shù)的發(fā)展，針對損傷盂唇縫合與不縫合存在爭議。陳廣等［10］回顧性分析24例SLAP損傷患者，比較肩關(guān)節(jié)鏡下帶線錨釘縫合修復(fù)上盂唇與單純清創(chuàng)治療Ⅱ型SLAP損傷的療效差異，結(jié)果表明，肩關(guān)節(jié)鏡下帶線錨釘縫合修復(fù)上盂唇較單純清創(chuàng)治療Ⅱ型SLAP損傷患者具有更好的臨床療效。本組病例中，選取Ⅱ、Ⅳ型SLAP損傷，關(guān)節(jié)鏡下探查除SLAP損傷外，是否有其他病變，如滑膜增生、關(guān)節(jié)內(nèi)游離體、關(guān)節(jié)囊松弛及肩盂骨質(zhì)缺損等，視情況行相應(yīng)處理。用刨削刀或磨鉆處理創(chuàng)面或去骨皮質(zhì)，得到出血或新鮮的骨創(chuàng)面以利于盂唇的重新附著后的愈合。根據(jù)術(shù)中盂唇清創(chuàng)情況，于SLAP損傷處行或不行錨釘固定修復(fù)，再于結(jié)節(jié)間溝下切斷肱二頭肌長頭腱，予以鉆孔固定，關(guān)節(jié)外切斷肱二頭肌腱較關(guān)節(jié)內(nèi)切斷減少了術(shù)后關(guān)節(jié)內(nèi)的疼痛刺激因素。本組病例術(shù)后1年隨訪ASES評分和VAS評分較術(shù)前明顯改善，差異均有統(tǒng)計學(xué)意義（P ＜0.05）。在本組病例中17例采用肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定，18例采用肱二頭肌長頭腱切斷關(guān)節(jié)內(nèi)固定，手術(shù)時間差異無統(tǒng)計學(xué)意義（P＞0.05），兩種固定方式疼痛評分差異有統(tǒng)計學(xué)意義（P ＜0.05），說明肱二頭肌長頭腱關(guān)節(jié)內(nèi)固定是術(shù)后關(guān)節(jié)內(nèi)疼痛的刺激因素，鉆孔固定費用相對較低，腱骨愈合相對較好，長期療效確切。

總之，關(guān)節(jié)鏡及肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定治療老年SLAP損傷的臨床療效確切、手術(shù)創(chuàng)傷小、并發(fā)癥少、可早期行功能鍛煉，功能恢復(fù)快，是一種值得推廣的微創(chuàng)治療方法。然而，相對膝關(guān)節(jié)鏡而言，肩關(guān)節(jié)鏡操作技術(shù)難度高，學(xué)習(xí)曲線長，需要具備熟練的關(guān)節(jié)鏡操作技術(shù)和經(jīng)驗較為豐富的關(guān)節(jié)運動損傷專業(yè)醫(yī)師進行手術(shù)，才可取得理想的手術(shù)效果。

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［6］王玉理, 雷益, 徐化劍. 肩關(guān)節(jié)SLAP損傷MR直接造影與關(guān)節(jié)鏡的對照研究［J］. 齊齊哈爾醫(yī)學(xué)院學(xué)報, 2013,34（13）:1887-1888.

［7］蔣勇, 康匯, 李紅川, 等. SLAP損傷的分型、病理及治療［J/CD］. 中華肩肘外科電子雜志, 2015, 3（4）:53-56．

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Fu Shijie, Email: fu_fsj@sina.com

Therapeutic effect analysis of long head of biceps brachii tendectomy and intertubercular sulcus extraarticular tenodesis for treatment of senile SLAP injury

Zhao Jiasong, Wang Guoyou, Zeng Shengqiang,Bao Dingsu, Shen Huarui, Fu Shijie. Department of Bone and Joint, Southwest Medical University Affiliated Hospital of Traditional Chinese Medicine, Luzhou 646000 ,China

BackgroundWith the continuous improvement of people's life quality and the popularity of national sport, the number of people with athletic injury such as superior labral anterior and posterior （SLAP） lesion is on the rise. With the continuous development of minimally invasive shoulder arthroscopic technique and the increasing diagnostic level of shoulder joint disease, it is gradually realized that the SLAP lesion is an important factor which leads to shoulder dysfunction in clinic. The SLAP injury usually occurs in young people or special athletes. Pain is the main symptom, which increases during overhead throwing. Symptoms including interlocking, snapping and instability accompany sometimes, while complaints of instability are rare. Causes of SLAP lesion include the external force that affects biceps tendon, the instability of glenohumeral joint, etc. The rate of incidence for elderly is relatively low with degeneration as the common cause. Age is an important factor that affects the postoperative clinical result of SLAP repair. However, the elderly patient can still get good operation effects with effective postoperative rehabilitation therapy and the careful preoperative evaluation of patients' demands and operation risks. Tendectomy or tenodesis of long head of biceps brachii is an option for SLAP repair.Methods（1）General information. From January 2014 to January 2015, 35 patients with type II and IV SLAP lesions treated with shoulder arthroscopy in our hospital were retrospectively analyzed. Seventeen cases （9 males and 8 females） treated with long head of biceps brachii tendectomy and intertubercular sulcus extra-articular drilling and tenodesis （Group A） aged from 51 to 68 years with an average of 58.6 years, including 7 cases of left and 10 cases of right.Eighteen cases （11 males and 7 females） treated with long head of biceps brachii tendectomy and intraarticular tenodesis （Group B） aged from 51-68 years with an average of 59.8 years, including 8 cases of left and 10 cases of right. Before operation, the diagnosis of glenoid labrum injury was confirmed by history taking, physical examination and MRI examination. Relevant examinations and preparations were refined preoperatively without absolute contraindication of surgery and anesthesia.（2）Inclusive criteria.① The age was more than 50 years;②The symptoms of snapping and mechanical interlocking lasted for 3-6 months, and the rehabilitation exercise has no effect; ③The formal conservative treatment was ineffective for 6-8 months;④ Patients with shoulder instability. （3）Exclusive criteria. ①Patients with habitual shoulder dislocation; ②Patients with subacromial tenderness caused by subacromial bursitis; ③Patients with open wound or infection on shoulder; ④ Patients with injuries of other parts of body which made the execution of surgery impossible temporarily; ⑤ Patients with other chronic disease and infectious disease which made them unfit for surgical treatment.（4）Operative methods.After general anesthesia, the patient was in beach chair position with routine disinfection and draping. The anterolateral, posterior and anterior approaches of shoulder joint were applied to perform arthroscopy. The glenohumeral joint structure was explored initially during the operation to confirm the injury type （II or IV） of glenoid labrum. Meanwhile, other lesions such as synovial hyperplasia, intraarticular loose bodies, joint capsule relaxation, glenoid bone defects, etc. were checked. Corresponding treatments were given accordingly. For instance, the management of hyperplastic synovial membrane and the removal of loose bodies could be carried out in priority. The treatment of wound or the removal of bone cortex was carried out with plane blade or grinding drill till the obtain of bleeding or fresh bone wound which facilitated the healing of glenoid labrum after reattachment. The choice of applying anchor fixation repair or not on SLAP lesion depended on the situation of the intraoperative debridement of glenoid labrum. Then, the long head tendon of biceps was cut off under arthroscopy, which was treated with intra-articular tenodesis or extra-articular intertubercular sulcus drilling and tenodesis. The wound was irrigated with a large amount of saline to prevent the drainage tube from plasma blockage, and the incision was sutured.（5）Postoperative management.The patient was given anti-infection, analgesia and discontinuous ice compress, and the shoulder joint was immobilized with brace in abduction position. The drainage tube was removed on the second day after operation. Following the step-by-step process, fist clenching and active and passive elbow movements were executed within 2 weeks postoperatively. The passive anteflexion, abduction and dorsiflexion of ipsilateral shoulder joint were carried out gradually. The painless active anteflexion, abduction and dorsiflexion of ipsilateral shoulder joint were conducted gradually 3 weeks later, and the painless full range activity of affected shoulder was started 6 weeks later. Muscle strength training was carried out 3 months after operation, and the original sports level was restored 6 months postoperatively.（6）Evaluating criteria.The function and ache situation of shoulder joint were evaluated preoperatively and postoperatively by the Rating scales of America shoulder and elbow surgeon's score （ASES） and visual analog scale （VAS）. The total score of ASES is 100 points, including 36 points for pain, 36 points for stability and 28 points for function. The higher the score, the better the shoulder function. The total VAS score is 10 points. 0 point: painless; 3 points or less: mild pain that is endurable; 4-6 points: moderate pain that affects sleep and is tolerable; 7-10 points:gradually intense pain that is intolerable and affects appetite and sleep.（7）Statistical analysis. The SPSS17.0 statistical software was used for data analysis. The measurement data was represented as x-±s with t test, and P ＜0.05 was considered as statistical difference.ResultsAll patients were followed up for 1 year. The postoperative ASES and VAS scores improved significantly compared to those before operation, and the differences between preoperative scores and postoperative scores were statistically significant（P ＜0.05）. The operation time between the two groups had no statistical difference （P＞0.05）. No patient had nerve injury, wound infection and other complications.ConclusionsIn treating senile SLAP lesion, the arthroscopic long head of biceps brachii tendectomy and intertubercular sulcus extra-articular tenodesis achieves definite clinical effect, minor surgical trauma, few complications, early functional exercises and quick function recovery. Hence, it is a minimal invasive method that is worth of promotion.Compared to that of knee arthroscopy, however, the operation technique of shoulder arthroscopy has high difficulty and long learning curve. Thus, it requires joint athletic injury specialists who are skilled and experienced in arthroscopy operation to achieve ideal surgical effects.

Arthroscopy; Long head of biceps tendon; Intertubercular sulcus; Elderly patients;SLAP lesion

10.3877/cma.j.issn.2095-5790.2017.03.005

西南醫(yī)科大學(xué)應(yīng)用基礎(chǔ)研究計劃項目（2015-YJ049）；西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院聯(lián)合專項項目（2016-4-25）；西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院聯(lián)合專項項目（2016-4-4）

646000 瀘州， 西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院骨關(guān)節(jié)科

扶世杰，Email：fu_fsj@sina.com

2016-07-05）

（本文編輯：李靜；英文編輯：陳建海、張曉萌、張立佳）

趙加松,汪國友,曾勝強,等. 肱二頭肌長頭腱切斷結(jié)節(jié)間溝下關(guān)節(jié)外固定治療老年SLAP損傷患者的療效分析［J/CD］.中華肩肘外科電子雜志,2017,5（3）：180-185.