摘要目的 对比关节镜下肱二头肌长头腱(long head of biceps tendon，LHBT)转位固定术与切断术两种术式联合肩袖修补术治疗巨大肩袖撕裂患者的临床效果。方法 回顾性分析2018年3月至2020年8月因巨大肩袖撕裂于民航总医院行关节镜下LHBT转位固定术与LHBT切断术联合肩袖修补术的44例患者临床资料，其中男15例，女29例；年龄40~80岁，平均(63.1±8.4)岁；LHBT转位固定组21例，LHBT切断组23例。所有患者术前MRI检查显示前上或后上型巨大肩袖撕裂，并经术中证实为可修复巨大肩袖撕裂。术后1个月、3个月、1年定期随访患者，比较两组患者术前及术后肩关节活动度、疼痛视觉模拟评分(visual analogue scale，VAS)、美国加州大学洛杉矶分校(University of California Los Angeles，UCLA)评分及ConstantMurley评分情况。术后3个月、1年复查肩关节MRI观察肩袖肌腱愈合情况及测量最短肩峰-肱骨头间隙(acromio-humeral interval，AHI)。结果 44例患者均获得随访，术后随访11~13个月，平均随访(12.1±0.4)个月。术后1年LHBT转位固定组VAS评分由术前(7.6±1.4)分下降至(1.1±1.8)分，UCLA评分由术前(14.8±6.7)分上升至(32.1±4.9)分，Constant-Murley评分由术前(52.4±21.4)分上升至(92.8±13.0)分，AHI由术前(6.0±1.6)mm上升至(8.5±1.1)mm，差异均有统计学意义(P＜0.05)。术后1年LHBT切断组VAS评分由术前(7.7±1.4)分下降至(1.0±1.3)分，UCLA评分由术前(13.6±5.2)分上升至(32.9±2.7)分，Constant-Murley评分由术前(51.2±23.0)分上升至(95.2±6.4)分，差异均有统计学意义(P＜0.05)。AHI由术前(5.8±1.6)mm上升至(6.3±1.3)mm，但差异无统计学意义(P＞0.05)。两组患者术后1年肩关节活动度、VAS评分、UCLA评分、Constant-Murley评分对比差异均无统计学意义(P＞0.05)，但LHBT切断组AHI明显小于LHBT转位固定组，差异有统计学意义(P＜0.001)。LHBT转位固定组术后无患者发生肩袖再撕裂，LHBT切断组有2例患者术后肩袖再撕裂，两组再撕裂率对比差异无统计学意义(P＞0.05)。结论 LHBT转位固定术和切断术联合肩袖修补术治疗巨大肩袖撕裂均可获得良好的临床效果，LHBT转位固定术在没有明显增加手术难度的前提下能够增强肩袖的力学强度并获得更佳的肩峰下间隙。
Abstract：Objective To compare the clinical outcomes of arthroscopic transpositive tenodesis and tenontotomy of biceps tendon in treating massive rotator cuff tears.Methods From March 2018 to August 2020，a total of 44 patients with massive rotator cuff tear received arthroscopic rotator cuff repair surgery in Civil Aviation General Hospital，and the data were retrospectively analyzed.The patients included 15 males and 29 females and aged 40~80 years，with an average age of (63.1±8.4)years.There were 21 patients in transpositive tenodesis group，and 23 patients in tenontotomy group.All the patients were diagnosed as anterior-superior or posterior-superior massive rotator cuff tears based on MRI and arthroscopy images.The postoperative follow ups were conducted in the 1st，3rd and 12th months.Both groups were evaluated according to the range of motion(ROM)，visual analogue scale(VAS)，University of California Los Angeles(UCLA) scores and Constant-Murley scores before and after the surgery.The conditions of rotator cuff healing and acromio-humeral interval (AHI)were assessed using magnetic resonance imaging(MRI).Results 44 cases were followed up for 11 to 13 months，with an average of (12.1±0.4)months.In the transpositive tenodesis group 12 months after operation，the VAS score decreased from (7.6±1.4)points before surgery to (1.1±1.8)points afer surgery，the UCLA score increased from (14.8±6.7)points before surgery to (32.1±4.9)points，after surgery，the Constant-Murley score increased from (52.4±21.4)points before surgery to (92.8±13.0)points afer surgery，the AHI increased from (6.0±1.6)mm before surgery to (8.5±1.1)mm after surgery.All the difference were statistically significant (P＜0.05).In the tenontotomy group 12 months after operation，the VAS score decreased from (7.7±1.4)points to (1.0±1.3)points，the UCLA score increased from (13.6±5.2)points to (32.9±2.7)points，the ConstantMurley score increased from (51.2±23.0)points to (95.2±6.4)points after surgery.All the difference were statistically significant (P＜0.05).Although the AHI increased from preoperative (5.8±1.6)mm to postoperative (6.3±1.3)mm in the tenontotomy group，there was no significant difference(P＞0.05).There were no significant differences in range of motion，the VAS score，the UCLA score and the ConstantMurley score between 2 groups 12 months after operation (P＞0.05)，while the AHI of tenontotomy group was much less than that of transpositive tenodesis group (P＜0.001).Although there were 2 cases of rotator cuff retear in tenontotomy group and no case of rotator cuff retear in transpositive tenodesis group，no statistical difference was observed(P＞0.05).Conclusion Both arthroscopic transpositive tenodesis and tenontotomy of biceps tendon can achieve satisfactory clinical outcomes in treating massive rotator cuff tears.Without increasing surgical difficulty obviously，arthroscopic transpositive tenodesis of biceps tendon can improve mechanical strength of rotator cuff and get better subacromial space.
［1］Chakravarty K，Webley M.Shoulder joint movement and its relationship to disability in the elderly［J］.J Rheumatol，1993，20(8)：1359-1361.
［2］Christopher KJ，Felix HS.Arthroscopic repair of large and massive rotator cuff tear［J］.Arthroscopy，2003，19(6)：564-571.
［3］Eugene MW，William TP，Vivek A.Arthroscopic rotator cuff repair：4-to 10-year results［J］.Arthroscopy，2004，20(1)：5-12.
［4］De Orio JK，Cofield RH.Results of a second attempt at surgical repair of a failed initial rotator-cuff repair［J］.J Bone Joint Surg Ame，1984，66(4)：563-567.
［5］Gerber C，Fuchs B，Hodler J.The results of repair of massive tears of the rotator cuff［J］.J Bone Joint Surg Am，2000，82(4)：505-515.
［6］Boutsiadis A，Chen S，Jiang C，et al.Long Head of the biceps as a suitable available local tissue autograft for superior capsular reconstruction：“The Chinese Way”［J］.Arthrosc Tech，2017，6(5)：e1559-e1566.
［7］尚西亮，吕婧仪，陈疾忤，等.关节镜下肱二头肌长头腱转位固定辅助替代上关节囊重建(Chinese Way)修补巨大及不可修复肩袖撕裂的临床疗效［J］.中国运动医学杂志，2019，8，(38)：652-657.
［8］胡益华，阳春华，李聪，等.关节镜下保留二头肌肌腱转位固定术治疗巨大肩袖撕裂的疗效分析［J］.中国现代医学杂志，2019，3(29)：74-77.
［9］Zhang Q，Zhou J，Ge H，et al.Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears：a prospective randomised trial［J］.Knee Surg Sports Traumatol Arthrosc，2015，23：464-469.
［10］Desai SS，Mata HK.Long head of biceps tendon pathology and results of tenotomy in full-thickness reparable rotator cuff tear［J］.Arthroscopy，2017，33(11)：1971-1976.
［11］金京日，何远铭，金日，等.关节镜下肱二头肌长头腱切断术在中老年巨大肩袖撕裂修补术中的应用［J］.中国骨科临床与基础研究杂志，2019，8(11)：197-203.
［12］Burkhart SS.Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears.A suspension bridge model［J］.Clin Orthop Relat Res，1992(284)：144-152.
［13］Herrmann SJ，Izadpanah K，Sudkamp NP，et al.Tears of the rotator cuff.Causesdiagnosis-treatment［J］.Acta Chir Orthop Traumatol Cech，2014，81(4)：256-266.
［14］Murthi AM，Vosburgh CL，Neviaser TJ.The incidence of pathologic changes of the long head of the biceps tendon［J］.J Shoulder Elbow Surg，2000，9 (5)：382-385.
［15］Baggio M，Martinelli F，Netto MB，et al.Evaluation of the results from arthroscopic tenodesis of the long head of the biceps brachii on the tendon of the subscapularis muscle［J］.Rev Bras Ortop，2016，51(2)：157-162.
［16］Kempf JF，Gleyze P，Bonnomet F，et al.A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty［J］.Arthroscopy，1999，15(1)：56-66.
［17］Desai SS，Mata HK.Long head of biceps tendon pathology and results of tenotomy in fullthickness reparable rotator cuff tear［J］.Arthroscopy，2017，33(11)：1971-1976.
［18］Kelly AM，Drakos MC，Fealy S，et al.Arthroscopic release of the long head of the biceps tendon：Functional outcome and clinical results［J］.Am J Sports Med，2005，33(2)：208-213.
［19］Jeong HY，Kim HJ，Jeon YS，et al.Factors predictive of healing in large rotator cuff tears：is it possible to predict retear preoperatively?［J］.Am J Sports Med，2018，46(7)：1693-1700.
［20］Chung SW，Kim JY，Kim MH，et al.Arthroscopic repair of massive rotator cuff tears：outcome and analysis of factors associated with healing failure or poor postoperative function［J］.Am J Sports Med，2013，41(7)：1674-1683.
［21］Cho NS，Cha SW，Rhee YG.Funnel tenotomy versus intracuff tenodesis for lesions of the long head of the biceps tendon associated with rotator cuff tears［J］.Am J Sports Med，2014，42(5)：1161-1168.
［22］Wittstein JR，Queen R，Abbey A，et al.Isokinetic strength，endurance，and subjective outcomes after biceps tenotomy versus tenodesis：a postoperative study［J］.Am J Sports Med，2011，39(4)：857-865.
［23］Han F，Kong CH，Hasan MY，et al.Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps：A biomechanical study on cadavers［J］.Orthop Traumatol Surg Res，2019，105(2)：257-263.
［24］Cordasco FA，Bigliani LU.Large and massive tears［J］.Orthop Clin N Am，1997，28(2)：179-193.
［25］张芳，屈辉.肩部撞击综合征的发生机制和影像学表现［J］.中国医学影像技术，2008，24(6)：823-825.
晋公网安备 14010702070875号