一文读懂肩袖损伤的治疗

学术   健康   2024-10-09 19:19   浙江  


首先申明肩袖损伤的治疗原则



1、缓解损伤局部的炎症反应、消除疼痛;
2、重建肩袖的力学平衡机制,促进肩关节功能的恢复,以满足生活和运动需要。



适应症、时机、原则




1、手术适应症:

肩袖完全损伤的患者应采取手术治疗、保守治疗效果不理想时应及时采用手术治疗。

对于肩袖完全损伤的患者除因年迈体弱、对功能要求不高或伴有严重内科疾患不宜手术外,均应争取早期手术

2、手术时机:

伤后 3 周内手术效果最好,早期手术可恢复肩袖原有张力,防止肌肉萎缩和软组织病变的发展。

3、手术原则:

切除撕裂口边缘坏死腱性组织,恢复肩袖解剖连续性,恢复肩峰下滑动。




手术治疗




肩袖撕裂伤的手术治疗分为开放手术关节镜下手术

1、开放手术

切开肩关节皮肤,找到损伤处,行缝合修补。目前开放手术较少使用,多采用微创治疗。



术后需卧床休养,肩关节固定于外展、前屈、外旋位 6 ~ 8 周;避免肩关节过度负重,防止再次发生肩袖损伤;定期复查。

2、关节镜手术

关节镜手术治疗肩袖撕裂有三种方法:


①肩峰下减压成形和肩袖修复术;

②肩关节病灶清创和小切口辅助下肩袖修复术;


③单纯肩关节镜下清创术。



关节镜能够直观显示肩袖断裂的范围、大小、形态,对肩关节退变、滑膜的炎性改变、冈上肌腱、肱二头肌长头部分断裂及肱二头肌腱半脱位、肩关节盂唇分离、盂肱关节软骨面的损伤和滑膜炎等疾患作出诊断并镜下手术治疗。


通过关节镜从肩峰下滑囊可观察滑囊病变冈上肌腱滑囊面的断裂,其效果是影像学检查及传统的开放手术下观察无法比拟的。




肩袖关节镜修复




1、单排缝合修复


小至中度的肩袖撕裂采用单排法修复。(直径 < 10 mm 为小撕裂,10~30 mm 为中度撕裂)




2. 双排缝合修复

大至大面积撕裂采用双排法修复。(30~50 mm 为大撕裂,> 50 mm 为巨大撕裂)




与开放手术一样,术后需卧床休养,肩关节固定于外展、前屈、外旋位 6~8 周;避免肩关节过度负重,防止再次发生肩袖损伤;定期复查。

关节镜手术最常见的并发症是关节软骨面损伤


由于软骨损伤后修复困难,在进行关节镜检查和手术时,所用的器械不可强力插入关节间隙或在软骨表面划动,应在直观下进行手术操作




附1:肩袖损伤双排修复法















附2:肩袖缝合方法





1、新月形肩袖撕裂


2、U 型或 v 型肩袖撕裂

①U 形撕裂在前后方向具有良好的移动性,采用边缘聚合技术原则先进行侧-侧缝合

无张力下将边缘修复到骨床。


3、L 型和倒 L 型肩袖撕裂

  • 急性 L 型和倒 L 型肩袖撕裂

①先从纵行劈裂的部位修复。

②边缘聚合修复到骨床。


  • 慢性 L 型和倒 L 型肩袖撕裂

① L 形撕裂在前后方向具有良好的移动性,而撕裂的单侧(通常是后叶)活动性更好。依据边缘聚合的技术原则先进行侧-侧缝合

② 无张力下边缘聚合修复到骨床。


4、巨大的、挛缩性、新月形肩袖撕裂

松解冈上肌和冈下肌间隙,进行双间隙滑动。首次施行前间隙滑动,然后施行后侧间隙滑动。

②松解后,改善冈上肌和冈下肌及小圆肌肌腱的活动(箭头所示)。

无张力方式缝合至侧面骨床修复冈上肌肌腱,冈下肌和小圆肌肌腱向侧方推移

余下的缺损使用侧-侧缝合关闭





保守治疗




肩袖部分损伤的患者以保守治疗为主,保守治疗效果不理想时应及时采用手术治疗。

保守治疗主要包括药物治疗、理疗外展架或石膏固定治疗

1、药物治疗:

非甾体类药物,消炎止痛等治疗。


2、理疗:


超短波可起到对肩关节局部消炎止痛的作用


3、外展架或石膏固定治疗:

可用石膏/外展架将肩关节固定在外展、前屈、外旋位 3~4 周,以使肩袖断裂部分接近而获得愈合,然后进行肩关节功能练习


如经 4~6 周严格非手术疗法仍不能恢复肩关节有力、无痛、主动的外展活动,则需考虑手术修补。


治疗过程中,即使效果满意、疼痛减轻,也应注意修养患肩不得突然发力或过度用力,否则会再发肩袖损伤,甚至加重损伤。


作者:孙小六

图源:文末文献
参考文献(特别特别多)

1.Deydre S. Teyhen, PT, PhD, Editor, and Jeanne Robertson, Illustrator.(2020). Painful Shoulder: Exercise Can Reduce Pain and Improve Mobility and Function. Journal of Orthopaedic & Sports Physical Therapy, 50(3), 142–142. doi:10.2519/jospt.2020.0501 

2.Brindisino, Fabrizio; Giovannico, Giuseppe; Maselli, Filippo (2019). Conservative management in a patient with massive rotator cuff tear and rheumatoid arthritis. Journal of Back and Musculoskeletal Rehabilitation, (), 1–9. doi:10.3233/BMR-171069 

3.Sari, Aylin; Eroglu, Ali (2019). Comparison of ultrasound-guided platelet rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions. Journal of Back and Musculoskeletal Rehabilitation, (), 1–10. doi:10.3233/BMR-191519 

4.Keener, Jay D.; Patterson, Brendan M.; Orvets, Nathan; Chamberlain, Aaron M. (2018). Degenerative Rotator Cuff Tears. Journal of the American Academy of Orthopaedic Surgeons, (), 1–. doi:10.5435/JAAOS-D-17-00480 

5.Dang, Alexis; Davies, Michael (2018). Rotator Cuff Disease. Sports Medicine and Arthroscopy Review, 26(3), 129–133. doi:10.1097/JSA.0000000000000207

6.Graham, Patrick (2018). Rotator Cuff Tear. Orthopaedic Nursing, 37(2), 154–156. doi:10.1097/NOR.0000000000000441 

Oh, Joo Han; Park, Min Suk; Rhee, Sung Min (2018). Treatment Strategy for Irreparable Rotator Cuff Tears. Clinics in Orthopedic Surgery, 10(2), 119–. doi:10.4055/cios.2018.10.2.119

7.Samim, Mohammad; Walsh, Pamela; Gyftopoulos, Soterios; Meislin, Robert; Beltran, Luis S. (2018). Postoperative MRI of Massive Rotator Cuff Tears. American Journal of Roentgenology, (), 1–9. doi:10.2214/AJR.17.19281  

8.Kalia, Vivek; Freehill, Michael T.; Miller, Bruce S.; Jacobson, Jon A. (2018). Multimodality Imaging Review of Normal Appearance and Complications of the Postoperative Rotator Cuff. American Journal of Roentgenology, (), 1–10. doi:10.2214/AJR.18.19648 

9.Sano, Hirotaka; Tokunaga, Masako; Noguchi, Moriyuki; Inawashiro, Takashi; Irie, Taichi; Abe, Hiroo; Yokobori, A. Toshimitsu (2017). Tight medial knot tying may increase retearing risk after transosseous equivalent repair of rotator cuff tendon. Bio-Medical Materials and Engineering, 28(3), 267–277. doi:10.3233/bme-171673 

10.Seven, M.M.; Ersen, O.; Akpancar, S.; Ozkan, H.; Turkkan, S.; Yıldız, Y.; Koca, K. (2017). Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthopaedics & Traumatology: Surgery & Research, 103(3), 427–433. doi:10.1016/j.otsr.2017.01.003 

11.Lin, Kenneth M.; Wang, Dean; Dines, Joshua S. (2017). Injection Therapies for Rotator Cuff Disease. Orthopedic Clinics of North America, (), S0030589817302079–. doi:10.1016/j.ocl.2017.11.010 

12.Shin, Yun Kyung; Ryu, Kyung Nam; Park, Ji Seon; Jin, Wook; Park, So Young; Yoon, Young Cheol (2017). Predictive Factors of Retear in Patients With Repaired Rotator Cuff Tear on Shoulder MRI. American Journal of Roentgenology, (), 1–8. doi:10.2214/AJR.17.17915 

13.Lewis, Jeremy (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, (), S1356689X16000400–. doi:10.1016/j.math.2016.03.009 

14.Christensen, Birgitte Hede; Andersen, Kathrine Skov; Rasmussen, Sten; Andreasen, Elizabeth Lykholt; Nielsen, Lotte Mejlvig; Jensen, Steen Lund (2016). Enhanced function and quality of life following 5 months of exercise therapy for patients with irreparable rotator cuff tears – an intervention study. BMC Musculoskeletal Disorders, 17(1), 252–. doi:10.1186/s12891-016-1116-6 

15.Lewis, Jeremy; McCreesh, Karen; Roy, Jean-Sébastien; Ginn, Karen (2015). Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. Journal of Orthopaedic & Sports Physical Therapy, (), 1–43. doi:10.2519/jospt.2015.5941 

Shin, S.-J.; Kook, S.-H.; Rao, N.; Seo, M.-J. (2015). Clinical Outcomes of Modified Mason-Allen Single-Row Repair for Bursal-Sided Partial-Thickness Rotator Cuff Tears: Comparison With the Double-Row Suture-Bridge Technique. The American Journal of Sports Medicine, 43(8), 1976–1982. doi:10.1177/0363546515587718 

16.Eajazi, Alireza; Kussman, Steve; LeBedis, Christina; Guermazi, Ali; Kompel, Andrew; Jawa, Andrew; Murakami, Akira M. (2015). Rotator Cuff Tear Arthropathy: Pathophysiology, Imaging Characteristics, and Treatment Options. American Journal of Roentgenology, 205(5), W502–W511. doi:10.2214/AJR.14.13815 

17.Beom, Jaewon; Jang, Hye Jin; Han, Tai Ryoon; Oh, Byung-Mo; Paik, Nam-Jong; Yang, Eun Joo; Lee, Shi-Uk (2015). Fatty replacement of rotator cuff in brain-injured patients is associated with hemiplegic arm function, but not with tendon tear: A multicenter study. NeuroRehabilitation, 37(2), 213–219. doi:10.3233/NRE-151254 

18. 坎贝尔骨科手术学

19. 实用骨科手术学

20.Chang, Eric Y.; Szeverenyi, Nikolaus M.; Statum, Sheronda; Chung, Christine B. (2014). Rotator Cuff Tendon Ultrastructure Assessment With Reduced-Orientation Dipolar Anisotropy Fiber Imaging. American Journal of Roentgenology, 202(4), W376–w378. doi:10.2214/AJR.13.11302 

21.Taneja, Atul K.; Kattapuram, Susan V.; Chang, Connie Y.; Simeone, F. Joseph; Bredella, Miriam A.; Torriani, Martin (2014). MRI Findings of Rotator Cuff Myotendinous Junction Injury. American Journal of Roentgenology, 203(2), 406–411. doi:10.2214/ajr.13.11474 

22.Millett, P. J.; Warth, R. J. (2014). Posterosuperior Rotator Cuff Tears: Classification, Pattern Recognition, and Treatment. Journal of the American Academy of Orthopaedic Surgeons, 22(8), 521–534. doi:10.5435/jaaos-22-08-521 

23.Omid, R.; Lee, B. (2013). Tendon Transfers for Irreparable Rotator Cuff Tears. Journal of the American Academy of Orthopaedic Surgeons, 21(8), 492–501. doi:10.5435/JAAOS-21-08-492

24.0Kim, Kyung Cheon; Shin, Hyun Dae; Lee, Woo Yong (2012). Repair Integrity and Functional Outcomes After Arthroscopic Suture-Bridge Rotator Cuff Repair. The Journal of Bone and Joint Surgery (American), 94(8), –. doi:10.2106/jbjs.k.00158 Kostas J. Economopoulos; Stephen F. Brockmeier (2012). Rotator Cuff Tears in Overhead Athletes. , 31(4), –. doi:10.1016/j.csm.2012.07.005 

25.Rutten, M. J. C. M.; Jager, G. J.; Kiemeney, L. A. L. M. (2010). Ultrasound Detection of Rotator Cuff Tears: Observer Agreement Related to Increasing Experience. , 195(6), 0–0. doi:10.2214/ajr.10.4526 

26.Brian R. Neri; Keith W. Chan; Young W. Kwon (2009). Management of massive and irreparable rotator cuff tears. , 18(5), 0–818. doi:10.1016/j.jse.2009.03.013

27. 奈特骨科疾病手术图谱

28. 创伤骨科手术学

29.Lafosse, L.; Brzoska, R.; Toussaint, B.; Gobezie, R. (2008). The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique: Surgical Technique. JBJS Essential Surgical Techniques, os-90(Supplement_2_Part_2), 275–286. doi:10.2106/JBJS.H.00388 

30.Park, J.-Y.; Lhee, S.-H.; Choi, J.-H.; Park, H.-K.; Yu, J.-W.; Seo, J.-B. (2008). Comparison of the Clinical Outcomes of Single- and Double-row Repairs in Rotator Cuff Tears. The American Journal of Sports Medicine, 36(7), 1310–1316. doi:10.1177/0363546508315039 

31.Ofer Levy; Hannan Mullett; Sarah Roberts; Stephen Copeland (2008). The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. , 17(6), 0–870. doi:10.1016/j.jse.2008.04.005 

32. 奈特简明骨科学彩色图谱

33.Lafosse, Laurent (2007). The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique. The Journal of Bone and Joint Surgery (American), 89(7), 1533–. doi:10.2106/jbjs.f.00305 

34.Zingg, P.O. (2007). Clinical and Structural Outcomes of Nonoperative Management of Massive Rotator Cuff Tears. The Journal of Bone and Joint Surgery (American), 89(9), 1928–. doi:10.2106/JBJS.F.01073 、

35.Hambly, Niamh; Fitzpatrick, Patricia; MacMahon, Peter; Eustace, Stephen (2007). Rotator Cuff Impingement: Correlation Between Findings on MRI and Outcome After Fluoroscopically Guided Subacromial Bursography and Steroid Injection. American Journal of Roentgenology, 189(5), 1179–1184. doi:10.2214/ajr.07.2421 

36.Maxwell C. Park; Neal S. ElAttrache; James E. Tibone; Christopher S. Ahmad; Bong-Jae Jun; Thay Q. Lee (2007). Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. , 16(4), 0–468. doi:10.1016/j.jse.2006.09.010 

37.Duc, Sylvain R.; Mengiardi, Bernard; Pfirrmann, Christian W. A.; Jost, Bernhard; Hodler, Juerg; Zanetti, Marco (2006). Diagnostic Performance of MR Arthrography After Rotator Cuff Repair. American Journal of Roentgenology, 186(1), 237–241. doi:10.2214/AJR.04.1818 

38.Stephen S. Burkhart; Craig D. Morgan; W.Ben Kibler (2003). The disabled throwing shoulder: Spectrum of pathology part I: Pathoanatomy and biomechanics. , 19(4), 404–420. doi:10.1053/jars.2003.50128 

39.Dr Field T. Blevins (1997). Rotator Cuff Pathology in Athletes. , 24(3), 205–220. doi:10.2165/00007256-199724030-00009 

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