肩胛下肌修復(fù)成功的十個(gè)要點(diǎn)

1. Diagnosis  1. 診斷

Various physical examination maneuvers aimed at diagnosing subscapularis tears have been described. Among these include the belly-off test,⁸ bear hug test,⁹ and lift-off test.¹⁰ The sensitivity and specificity of these tests are highly variable (Video 1).¹¹ One recent study found that the bear hug test had the greatest sensitivity (0.52) whereas the lift-off test had the greatest specificity (0.98).¹² However, both tests have poor accuracy in identifying small partial tears.¹³ Diagnostic accuracy may be enhanced by performing multiple subscapularis-specific provocative maneuvers.¹²
已有多種體格檢查方法被描述用于診斷肩胛下肌撕裂，其中包括腹部離位試驗(yàn)、 ⁸ 熊抱試驗(yàn)、 ⁹ 和抬離試驗(yàn)。 ¹⁰ 這些試驗(yàn)的敏感性和特異性差異很大（ Video 1 ）。 ¹¹ 一項(xiàng)近期研究發(fā)現(xiàn)熊抱試驗(yàn)的敏感性最高（0.52），而抬離試驗(yàn)的特異性最高（0.98）。 ¹² 然而，這兩種試驗(yàn)在識(shí)別小范圍部分撕裂時(shí)準(zhǔn)確性較差。 ¹³ 通過(guò)執(zhí)行多個(gè)肩胛下肌特異性誘發(fā)試驗(yàn)可以提高診斷準(zhǔn)確性。 ¹²

In patients who exhibit physical examination signs concerning subscapularis pathology, magnetic resonance imaging (MRI) can aid in the diagnosis. Axial and parasagittal imaging planes may be particularly useful for evaluation of subscapularis tears (Fig 1).¹⁴ Axial views facilitate evaluation of the insertion of the subscapularis tendon on the lesser tuberosity.⁵ MRI also may visualize associated findings such as medial subluxation of the biceps tendon as well as avulsion and medial subluxation of a torn superior glenohumeral ligament (SGHL)-middle glenohumeral ligament (MGHL) complex, leading to the “comma sign” on arthroscopy.^5,15 The comma sign has been shown to have high sensitivity and specificity for subscapularis tears.¹⁶ In addition, maintaining a high index of suspicion for biceps tendon pathology in patients with subscapularis tears is important, because the authors of one study found that subscapularis tendon tears visualized on MRI were significant predictors of long head of the biceps tendon (LHBT) disorders visualized on arthroscopy.¹⁷ Failure to address the biceps tendon during arthroscopy can lead to future instability postoperatively.¹⁸ Furthermore, MRI allows for evaluation of fatty atrophy of the torn tendon, which is predictive of poor outcomes after rotator cuff repair.^19,20 Notably, smaller subscapularis tears can be missed on MRI more than 50% of the time.21, 22, 23, 24 As such, thorough arthroscopic evaluation is necessary to diagnose subscapularis tendon tears and determine the most appropriate surgical technique.
對(duì)于出現(xiàn)肩胛下肌病理體征的患者，磁共振成像（MRI）有助于診斷。軸向和旁矢狀成像平面可能特別適用于評(píng)估肩胛下肌撕裂（ Fig 1）。¹⁴軸向視圖有助于評(píng)估肩胛下肌腱在小結(jié)節(jié)上的止點(diǎn)。⁵MRI 還可以顯示相關(guān)發(fā)現(xiàn)，如肱二頭肌腱內(nèi)側(cè)半脫位，以及撕裂的盂肱上韌帶（SGHL）-盂肱中韌帶（MGHL）復(fù)合體的撕脫和內(nèi)側(cè)半脫位，這會(huì)導(dǎo)致關(guān)節(jié)鏡檢查時(shí)出現(xiàn)“逗號(hào)征”。⁵¹⁵研究表明，“逗號(hào)征”對(duì)肩胛下肌撕裂具有很高的敏感性和特異性。¹⁶此外，對(duì)于肩胛下肌撕裂的患者，保持對(duì)肱二頭肌腱病理的高度警惕非常重要，因?yàn)橐豁?xiàng)研究作者發(fā)現(xiàn)，MRI 上顯示的肩胛下肌腱撕裂是關(guān)節(jié)鏡檢查時(shí)顯示的肱二頭肌長(zhǎng)頭腱（LHBT）疾病的重要預(yù)測(cè)因素。¹⁷在關(guān)節(jié)鏡檢查中未能處理肱二頭肌腱可能導(dǎo)致術(shù)后不穩(wěn)定。¹⁸此外，MRI 可以評(píng)估撕裂肌腱的脂肪萎縮，這預(yù)示著肩袖修復(fù)后的不良預(yù)后。¹⁹²⁰值得注意的是，超過(guò) 50%的小型肩胛下肌撕裂在 MRI 上可能被遺漏。21,22,23,24 因此，需要進(jìn)行徹底的關(guān)節(jié)鏡評(píng)估，以診斷肩胛下肌腱撕裂并確定最合適的手術(shù)技術(shù)。

Fig 1.  圖 1。

2. Patient Positioning  2. 患者體位

Optimal patient positioning is critical to maximize surgical working space and achieve adequate visualization for subscapularis repair. The most common patient positions for shoulder arthroscopy are the lateral decubitus or beach-chair positions. The beach-chair position is most advantageous in the case of subscapularis repair. To achieve the beach-chair position, the patient is supine and placed into 10 to 15° of Trendelenberg, 45 to 60° of hip flexion, and 30° of knee flexion (Video 1, Fig 2).²⁵ A sterile arm-positioning device can be used to facilitate intraoperative arm adjustment, which provides a key benefit over the lateral decubitus position in which arm positioning is dictated by nonsterile traction and cannot be adjusted by the surgeon directly.²⁶ Rotation and forward flexion of the humerus opens up the anterior subdeltoid space for improved instrumentation and visualization of anterior shoulder structures.²⁷ The lack of traction required in the beach-chair position also reduces stress on the nearby brachial plexus.^26,28 Finally, it is easier to convert from an arthroscopic to open procedure with the patient in the beach-chair position because the patient already is supine.^25,27 The size and retraction of subscapularis tears can be underestimated on MRI, so easy conversion to an open repair if necessary is an important preoperative consideration.
最佳患者體位對(duì)于最大化手術(shù)操作空間和實(shí)現(xiàn)肩胛下肌修復(fù)的充分視野至關(guān)重要。肩關(guān)節(jié)鏡手術(shù)中最常見(jiàn)的患者體位是側(cè)臥位或沙灘椅位。對(duì)于肩胛下肌修復(fù)而言，沙灘椅位最為有利。要達(dá)到沙灘椅位，患者需仰臥，置于 10 至 15°的 Trendelenberg 位，髖關(guān)節(jié)屈曲 45 至 60°，膝關(guān)節(jié)屈曲 30°（ Video 1，Fig 2）。²⁵可使用無(wú)菌手臂固定裝置來(lái)輔助術(shù)中手臂調(diào)整，這比側(cè)臥位具有關(guān)鍵優(yōu)勢(shì)，因?yàn)樵趥?cè)臥位中手臂位置由非無(wú)菌牽引決定，且不能由外科醫(yī)生直接調(diào)整。²⁶肱骨旋轉(zhuǎn)和前屈可打開(kāi)前肩峰下間隙，從而改善前肩結(jié)構(gòu)的器械操作和視野。²⁷沙灘椅位無(wú)需牽引，也可減少對(duì)附近臂叢的應(yīng)力。²⁶²⁸最后，當(dāng)患者處于沙灘椅位時(shí)，從關(guān)節(jié)鏡手術(shù)轉(zhuǎn)為開(kāi)放手術(shù)更容易，因?yàn)榛颊咭呀?jīng)是仰臥位。²⁵²⁷ 肩胛下肌撕裂的大小和退縮程度在 MRI 上可能被低估，因此如果需要，能夠輕易轉(zhuǎn)為開(kāi)放修復(fù)是一個(gè)重要的術(shù)前考慮因素。

Fig 2.  圖 2。

3. Arthroscopic Confirmation and Classification—Probe Every Subscapularis!
3. 關(guān)節(jié)鏡確認(rèn)和分類——探查每一個(gè)肩胛下肌！

Arthroscopic evaluation is the ultimate diagnostic tool when evaluating tears of the subscapularis. Once adequate visualization is achieved, it is necessary to probe the tendon and visualize the entire footprint to determine tear size, direction, and retraction. The “comma sign” is a useful visual landmark for the superior edge of a retracted subscapularis that includes fibers from the SGHL and medial coracohumeral ligament (CHL) (Video 1, Fig 3).²⁹ Tendon tears can be categorized according to the Lafosse classification system, which includes 5 tear types according to tear size, degree of insertional detachment, and humeral head subluxation.³⁰ A 70° scope may be necessary to visualize the inferior extent of the footprint. The “posterior lever push” is a useful maneuver to improve visualization of the tendon insertion site. Grasping the elbow and applying posterior force to the humerus pulls the intact tendon fibers away from the footprint, improving the surgical field of view by 5 to 10 mm.³¹
關(guān)節(jié)鏡評(píng)估是診斷肩胛下肌撕裂的最終工具。一旦獲得充分的視野，就需要探查肌腱并觀察整個(gè)足跡，以確定撕裂的大小、方向和回縮情況。“逗號(hào)征”是觀察回縮的肩胛下肌上緣的一個(gè)有用視覺(jué)標(biāo)志，包括肩胛下橫韌帶（SGHL）和內(nèi)側(cè)喙肱韌帶（CHL）的纖維（ Video 1 ， Fig 3 ）。 ²⁹ 肌腱撕裂可以根據(jù) Lafosse 分類系統(tǒng)進(jìn)行分類，該系統(tǒng)根據(jù)撕裂大小、插入點(diǎn)脫位程度和肱骨頭半脫位程度分為 5 種撕裂類型。 ³⁰ 可能需要 70°的鏡來(lái)觀察足跡的下界。“后杠桿推”是一個(gè)有用的操作，可以改善肌腱插入點(diǎn)的視野。握住肘部并對(duì)肱骨施加后向力量，將完整的肌腱纖維從足跡中拉出，從而將手術(shù)視野改善 5 至 10 毫米。 ³¹

Fig 3.  圖 3。

After thorough subscapularis evaluation, attention must turn to the LHBT. The LHBT is stabilized within the bicipital groove by the SGHL, CHL, subscapularis, and supraspinatus.³² Fibers of subscapularis encircle the bicipital groove and merge to insert on the lesser tuberosity.³³ Subscapularis tears disrupt the soft-tissue stabilizers of the LHBT and can result in medial subluxation or dislocation of the biceps tendon from the groove.³⁴ Critical evaluation and probing of the LHBT intraoperatively can determine whether instability requiring tenotomy or tenodesis is present.
在徹底評(píng)估肩胛下肌后，注意力必須轉(zhuǎn)向左肩胛骨長(zhǎng)肌腱。左肩胛骨長(zhǎng)肌腱由肩胛下肌橫韌帶、肩胛下橫韌帶、肩胛下肌和岡上肌穩(wěn)定。 ³² 肩胛下肌的纖維環(huán)繞肱二頭肌溝并匯合插入小結(jié)節(jié)。 ³³ 肩胛下肌撕裂會(huì)破壞左肩胛骨長(zhǎng)肌腱的軟組織穩(wěn)定器，可能導(dǎo)致肱二頭肌長(zhǎng)肌腱從溝內(nèi)移位或脫位。 ³⁴ 手術(shù)中對(duì)左肩胛骨長(zhǎng)肌腱進(jìn)行仔細(xì)評(píng)估和探查，可以確定是否存在需要肌腱切斷術(shù)或肌腱縫合術(shù)的不穩(wěn)定情況。

4. Address the Biceps Tendon
4. 處理肱二頭肌腱

Subluxation of the biceps tendon in the setting of a subscapularis tear can be an important pain generator for patients with anterior shoulder pathology. If the medial sling of the biceps pulley is disrupted resulting in medial subluxation or dislocation of the tendon from the bicipital groove, then biceps tenotomy or tenodesis is indicated (Video 1). Biceps tenodesis can be achieved via an arthroscopic or open approach with tenodesis screws or soft-tissue anchors intra-articularly or in a suprapectoral or subpectoral position. Tenotomy can be performed arthroscopically by releasing the biceps tendon from within the glenohumeral joint (Fig 4).³⁵
肱二頭肌腱在肩胛下肌撕裂的情況下發(fā)生脫位，可能是前肩部病理患者的重要疼痛來(lái)源。如果肱二頭肌滑車內(nèi)側(cè)懸韌帶受損，導(dǎo)致肌腱從肱二頭肌溝內(nèi)側(cè)脫位或半脫位，則應(yīng)進(jìn)行肱二頭肌腱切斷術(shù)或腱固定術(shù)（ Video 1 ）。肱二頭肌腱固定術(shù)可以通過(guò)關(guān)節(jié)鏡或開(kāi)放手術(shù)，使用關(guān)節(jié)內(nèi)腱固定螺釘或軟組織錨定裝置，在胸大肌上方或下方位置進(jìn)行。肱二頭肌腱切斷術(shù)可以通過(guò)關(guān)節(jié)鏡手術(shù)，從肩胛盂肱骨頭關(guān)節(jié)內(nèi)松解肱二頭肌腱（ Fig 4 ）。 ³⁵

Fig 4.  圖 4

The existing literature has reported little-to-no difference in functional outcomes for tenodesis versus tenotomy, so patient and surgeon preferences often dictate procedural selection.³⁶ Tenodesis may reduce exertional cramping and avoids the cosmetic “Popeye” deformity seen in 50% of patients posttenotomy.³⁶ However, tenodesis is more technically challenging and has risks including infection, loss of fixation, persistent anterior shoulder pain, and fractures especially with subpectoral boney fixation.^37,38 Tenotomy is used more commonly for low-demand elderly patients with combined biceps and rotator cuff pathology.³⁶ Maier et al.³⁹ found that in a limited case series of 21 patients, restabilization of the biceps tendon after acute traumatic subscapularis tears is a viable option without tenodesis or tenotomy, although literature concerning this technique is limited.
現(xiàn)有文獻(xiàn)報(bào)道，在二頭肌腱固定與切斷術(shù)之間，功能結(jié)果差異甚微或無(wú)差異，因此患者和外科醫(yī)生的選擇往往決定手術(shù)方式。 ³⁶ 二頭肌腱固定術(shù)可減少運(yùn)動(dòng)性痙攣，并避免 50%患者在腱切斷術(shù)后出現(xiàn)的“大力水手”樣畸形。 ³⁶ 然而，肌腱固定技術(shù)難度更大，存在感染、固定失效、持續(xù)性前肩疼痛和骨折等風(fēng)險(xiǎn)，尤其是在使用胸肌下骨性固定時(shí)。 ^37 38 肌腱切斷更常用于低需求老年患者，且合并肱二頭肌和肩袖病變。 ³⁶ Maier 等人 ³⁹ 在一項(xiàng) 21 例患者的有限病例系列研究中發(fā)現(xiàn)，在急性創(chuàng)傷性肩胛下肌撕裂后，通過(guò)非肌腱固定或肌腱切斷術(shù)進(jìn)行肱二頭肌腱再穩(wěn)定是可行的選擇，盡管關(guān)于該技術(shù)的文獻(xiàn)有限。

5. Portal Placement  5. 入路位置

Accurate portal placement is important to achieve adequate visualization and facilitate instrumentation and suture passing for repair. The standard posterior viewing portal is established first in the soft spot 2 cm distal and 2 cm medial to the posterolateral corner of the acromion. The anterior portal is then achieved via an outside-in technique through which a spinal needle is inserted just lateral to the tip of the coracoid and visualized within the glenohumeral joint from the posterior viewing portal to confirm appropriate positioning (Video 1, Fig 2).⁴⁰ Because this portal is used for medial anchor placement on the lesser tuberosity, the mid-anterior portal should be placed at a 5 to 10° angle to the lesser tuberosity. Anterolateral and anterolateral accessory portals also can be used to mobilize the tear and for suture management and instrumentation with suture passing devices, respectively, although repair techniques with a single anterior portal have been described.^41,42
準(zhǔn)確入路位置對(duì)于實(shí)現(xiàn)充分視野并方便器械操作和縫合修復(fù)至關(guān)重要。首先在肩峰后外側(cè)角遠(yuǎn)端 2 厘米、內(nèi)側(cè) 2 厘米的軟點(diǎn)處建立標(biāo)準(zhǔn)后視入路。然后通過(guò)由外向內(nèi)的技術(shù)建立前視入路，將脊柱針插入喙突尖外側(cè)，從后視入路觀察，以確認(rèn)適當(dāng)位置（圖 0，圖 1）。由于該入路用于在小結(jié)節(jié)上放置內(nèi)側(cè)錨釘，因此中前視入路應(yīng)與喙突成 5 至 10°角。前外側(cè)和前內(nèi)側(cè)輔助入路也可用于撕裂組織松解、縫合管理和使用縫合通過(guò)器械進(jìn)行器械操作，盡管已描述過(guò)使用單個(gè)前視入路的修復(fù)技術(shù)。圖 2 圖 3 圖 4

6. Achieving Adequate Exposure
6. 獲得充分的暴露

Obtaining adequate exposure is critical to operative success and may be achieved via a number of techniques. First, an anterior subdeltoid release may be performed. This release of the deep layer of the deltoid fascia increases arthroscopic visualization via the anterolateral and lateral portals.⁴³ Similarly, a rotator interval release using electrocautery or a shaver may improve surgical exposure. This includes debridement inferior to the coracoacromial ligament, removal of adhesions between the subscapularis and the coracoid, and release of the coracohumeral ligament from the coracoid laterally (Video 1, Fig 3).^44,45 Furthermore, a traction stitch may be used medial to the “comma” sign tissue in the case of retracted subscapularis tears to assist with tissue mobilization. The subscapularis should be further released in a 270° fashion being sure to free the tissue from adhesions anteriorly, superiorly, and posteriorly. During this process, the mobility of the tendon may be assessed using a grasper and care should be taken to ensure that the repair is not under excess tension. In cases of more severe pathology (LaFrosse grades 3-4), a brachial plexus release may be considered for cases in which the nerves are at risk of compression.
獲得充分的手術(shù)視野對(duì)手術(shù)成功至關(guān)重要，可以通過(guò)多種技術(shù)實(shí)現(xiàn)。首先，可以執(zhí)行前三角肌下松解術(shù)。這種肩胛骨筋膜深層釋放術(shù)可以通過(guò)前外側(cè)和外側(cè)通道增加關(guān)節(jié)鏡視野。 ⁴³ 類似地，使用電凝器或清創(chuàng)器進(jìn)行肩峰間釋放術(shù)可以改善手術(shù)視野。這包括在喙鎖韌帶下方進(jìn)行清創(chuàng)，移除肩胛下肌和喙突之間的粘連，以及從喙突外側(cè)釋放喙肱韌帶（ Video 1 ， Fig 3 ）。 ^44 45 此外，在肩胛下肌撕裂退縮的情況下，可以在“逗號(hào)”征組織內(nèi)側(cè)使用牽引線，以協(xié)助組織松解。肩胛下肌應(yīng)以 270°的方式進(jìn)一步釋放，確保從前方、上方和后方松解組織。在此過(guò)程中，可以使用抓持器評(píng)估肌腱的活動(dòng)性，并應(yīng)注意確保修復(fù)時(shí)肌腱不過(guò)度緊張。 在更嚴(yán)重的病理情況下（LaFrosse 分級(jí) 3-4 級(jí)），可以考慮進(jìn)行臂叢神經(jīng)松解術(shù)，以防神經(jīng)受壓。

7. When to Perform a Coracoplasty
7. 何時(shí)進(jìn)行喙突成形術(shù)

Anterior shoulder pain and subscapularis pathology can occur in the setting of a narrowed coracohumeral interval.^46,47 The average coracohumeral distance (CHD) has been estimated to be roughly 8.7 to 11 mm.46, 47, 48 One study found that the average CHD was 5.0 mm among patients undergoing arthroscopy for subscapularis tears compared with a CHD of 10.0 among patients who underwent shoulder arthroscopy for problems not related to the rotator cuff, subscapularis or subcoracoid space.⁴⁷ Kilic et al.⁴⁹ similarly found that CHD measurements are lower among patients with subscapularis tears than those without subscapularis tears among patients undergoing arthroscopy for rotator cuff repair. Analogous to acromioplasty for subacromial impingement, coracoplasty can be a valuable tool for decompression of the coracohumeral interval. Two recent studies have found comparable results in patients undergoing subscapularis repair with and without coracoplasty.^50,51 However, in our institution, we favor performing subcoracoid decompression with coracoplasty in those patients who have a CHD less than 7 mm (Video 1, Fig 5).46, 47, 48 When performed, coracoplasty may decrease anterior shoulder pain and allow for improved patient function post-operatively.
前肩疼痛和肩胛下肌病理可能發(fā)生在喙肱間距狹窄的情況下。 ⁴⁶⁴⁷平均喙肱距離（CHD）估計(jì)約為 8.7 至 11 毫米。46,47,48一項(xiàng)研究發(fā)現(xiàn)，接受肩關(guān)節(jié)鏡手術(shù)修復(fù)肩胛下肌撕裂的患者平均 CHD 為 5.0 毫米，而接受肩關(guān)節(jié)鏡手術(shù)解決與肩袖、肩胛下肌或副喙突間隙無(wú)關(guān)問(wèn)題的患者平均 CHD 為 10.0 毫米。⁴⁷Kilic 等人⁴⁹也發(fā)現(xiàn)，接受肩袖修復(fù)肩關(guān)節(jié)鏡手術(shù)的患者中，肩胛下肌撕裂患者的 CHD 測(cè)量值低于無(wú)肩胛下肌撕裂的患者。類似于肩峰下減壓術(shù)治療肩峰下撞擊癥，喙突成形術(shù)可以成為喙肱間距減壓的有效工具。最近的兩項(xiàng)研究發(fā)現(xiàn)，接受肩胛下肌修復(fù)并實(shí)施喙突成形術(shù)的患者結(jié)果相似。⁵⁰⁵¹然而，在我們機(jī)構(gòu)，我們傾向于對(duì) CHD 小于 7 毫米的患者實(shí)施副喙突減壓聯(lián)合喙突成形術(shù)。Video 1,Fig 546,47,48 當(dāng)進(jìn)行喙突成形術(shù)時(shí)，可能會(huì)減輕前肩疼痛，并允許患者術(shù)后功能得到改善。

Fig 5.  圖 5

8. Anchor Placement and Repair Techniques
8. 錨釘放置和修復(fù)技術(shù)

There are various factors that impact the success of surgical repair of the rotator cuff. There is evidence that double-row suture repair constructs lead to lower retear rates after rotator cuff repair.⁵² Similarly, there is cadaveric evidence that double-row repairs have biomechanical advantages in strength and stiffness for subscapularis repair.⁵³ We favor using double-row repair techniques for full-thickness tears and those that have retracted (Video 1). Small, upper border tears of the subscapularis may be treated with single-row constructs at our institution.
影響肩袖撕裂手術(shù)修復(fù)成功的因素有很多。有證據(jù)表明，雙排縫合修復(fù)結(jié)構(gòu)在肩袖修復(fù)后能降低再撕裂率。 ⁵² 同樣，也有尸體實(shí)驗(yàn)證據(jù)顯示，雙排修復(fù)在肩胛下肌修復(fù)方面在強(qiáng)度和剛度上具有生物力學(xué)優(yōu)勢(shì)。 ⁵³ 我們傾向于使用雙排修復(fù)技術(shù)處理全層撕裂和退縮撕裂（ Video 1 ）。我們機(jī)構(gòu)可能會(huì)用單排結(jié)構(gòu)治療肩胛下肌上部邊緣的小撕裂。

Anchor placement is similarly an important consideration during arthroscopic repair of the subscapularis (Fig 6).⁴⁹ There is evidence that medialization of the footprint of the subscapularis does not affect functional outcomes.⁵⁴ As such, in the case of immobile or retracted subscapularis tears, it is acceptable to medialize the insertion of the subscapularis repair. The mid anterior portal may be used in order to place the medial anchor. The placement of the medial anchors should be in the direction of the fibers of the subscapularis and thus the hand of the surgeon will pass near the face of the patient with the anchors placed in a medial to lateral direction. In addition, one may consider placing the lateral anchors in the bicipital groove in order to increase the stability of the construct. Finally, in cases of combined supraspinatus and subscapularis tears, the comma sign tissue should be kept intact. The upper border of the subscapularis can then be repaired to the comma sign tissue, which facilitates restoration of the native anatomy and repair of the subscapularis and supraspinatus.⁵⁵
錨釘?shù)姆胖迷诩珉蜗录￡P(guān)節(jié)鏡修復(fù)中同樣是一個(gè)重要的考慮因素（ Fig 6 ）。 ⁴⁹ 有證據(jù)表明，將肩胛下肌的止點(diǎn)向內(nèi)側(cè)移位不會(huì)影響功能結(jié)果。 ⁵⁴ 因此，在肩胛下肌撕裂無(wú)法移動(dòng)或回縮的情況下，可以將肩胛下肌修復(fù)的止點(diǎn)向內(nèi)側(cè)移位。可以使用中前方入路來(lái)放置內(nèi)側(cè)錨釘。內(nèi)側(cè)錨釘?shù)姆胖脩?yīng)沿著肩胛下肌纖維的方向，因此外科醫(yī)生的手將靠近放置錨釘?shù)幕颊呙娌浚^釘從內(nèi)側(cè)向外側(cè)放置。此外，可以考慮將外側(cè)錨釘放置在肱二頭肌溝中，以提高結(jié)構(gòu)的穩(wěn)定性。最后，在合并有岡上肌和肩胛下肌撕裂的情況下，應(yīng)保持逗號(hào)征組織完整。然后將肩胛下肌的上緣修復(fù)到逗號(hào)征組織上，這有助于恢復(fù)原生解剖結(jié)構(gòu)并修復(fù)肩胛下肌和岡上肌。 ⁵⁵

Fig 6.  圖 6。

9. Suture Management and Passing Pearls
9. 縫線管理和穿線技巧

Various methods may be used to pass sutures and tension the subscapularis repair after anchor placement. After placement of a double-loaded suture anchor in the subscapularis insertion site of the lesser tuberosity, one end of the suture is gathered and loaded onto the suture passer. The suture passer is then advanced through the subscapularis tendon in an anterior-to-posterior fashion, creating a loop.^56,57 Care should be taken to ensure that the tension of the repair is appropriate. This suture is then removed through the anterior portal. The suture anchor end is then advanced through the loop and traction is then applied to both ends of the suture. This brings the anchor end of the suture out of the anterior portal. The surgeon may then elect to proceed with using this process to create a mattress suture construct or he or she may tie the suture in a simple knot fashion.⁵⁶ At our institution, we favor the use of mattress constructs for subscapularis repairs as we feel that this provides additional strength for the repair (Video 1, Fig 7).^58,59 Knotless repair strategies also have been described, particularly for upper subscapularis tendon injuries.^58,59 There are data showing that knotless constructs produce similar results to knotted single anchor repair techniques in these specific injury patterns.⁶⁰ A cadaveric study similarly found no differences in single anchor?knotted constructs compared with knotless fixation for treatment of full-thickness upper border subscapularis injuries.⁶¹
在錨釘放置后，可以使用多種方法穿過(guò)縫線并對(duì)肩胛下肌修復(fù)進(jìn)行張緊。在 lesser tuberosity 的肩胛下肌附著點(diǎn)放置雙載荷縫線錨釘后，將縫線的一端收集并加載到縫線傳遞器上。然后通過(guò)肩胛下肌腱從前向后推進(jìn)縫線傳遞器，形成一個(gè)環(huán)。 ⁵⁶⁵⁷應(yīng)注意確保修復(fù)的張力適當(dāng)。然后通過(guò)前側(cè)通道移除縫線。將縫線錨釘端通過(guò)環(huán)推進(jìn)，然后對(duì)縫線的兩端施加牽引。這使縫線錨釘端從前側(cè)通道出來(lái)。外科醫(yī)生可以選擇使用此過(guò)程來(lái)創(chuàng)建墊狀縫線結(jié)構(gòu)，或者可以簡(jiǎn)單地打結(jié)。⁵⁶在我們機(jī)構(gòu)，我們傾向于使用墊狀結(jié)構(gòu)進(jìn)行肩胛下肌修復(fù)，因?yàn)槲覀冋J(rèn)為這為修復(fù)提供了額外的強(qiáng)度（Video 1，Fig 7）。⁵⁸⁵⁹無(wú)結(jié)修復(fù)策略也已描述，特別是用于上肩胛下肌腱損傷。⁵⁸⁵⁹有數(shù)據(jù)顯示，在特定損傷模式中，無(wú)結(jié)結(jié)構(gòu)產(chǎn)生的效果與單錨釘修復(fù)技術(shù)相似。⁶⁰一項(xiàng)尸體研究表明，在治療全層上緣肱二頭肌腱損傷時(shí)，單錨釘結(jié)構(gòu)與無(wú)結(jié)固定相比沒(méi)有差異。 ⁶¹

Fig 7.  圖 7。

10. Postoperative Course and Rehabilitation
10. 術(shù)后進(jìn)程與康復(fù)

Postoperative rehabilitation is paramount to the overall success of subscapularis repair. Goals of early rehabilitation include maintenance of hand, wrist, and elbow range of motion while protecting the operative repair and limiting nearby inflammation.⁶² As such, for the first 4 weeks after repair, we favor the use of a sling, which assists with patient comfort and protects from excessive motion of the operative arm (Video 1, Fig 8). In the immediate postoperative period, patients may benefit from cryotherapy in order to decrease swelling, improve pain control, and decrease the inflammatory response to surgery.⁶³ After subscapularis repair, patients follow a protocol in which gradual return of range of motion may be followed. Although active range of motion of the hand, wrist, and elbow is encouraged in the early postoperative period, active range of motion of the shoulder should be restricted during the first 4 weeks. Passive range of motion postoperatively may decrease stiffness and adhesions and is thus acceptable. However, at our institution, we counsel patients to avoid greater than 30° of external rotation (passive or active) in the first 4 to 6 weeks postoperatively as this can cause excessive tension on the repair. Depending on the tension of the repair, the sling may be discontinued and assisted active and active range of motion exercises may be initiated at 5 to 6 weeks postoperatively. Rehabilitation then continues with exercises focused on regaining muscular endurance and range of motion.⁶² Finally, exercises to increase muscle strength and power are slowly reintroduced before patients return to their previous activities.⁶²
術(shù)后康復(fù)對(duì)于肩胛下肌修復(fù)的整體成功至關(guān)重要。早期康復(fù)的目標(biāo)包括維持手、腕和肘關(guān)節(jié)的活動(dòng)范圍，同時(shí)保護(hù)手術(shù)修復(fù)部位并限制附近炎癥。因此，在修復(fù)后的前 4 周，我們傾向于使用吊帶，這有助于患者舒適并保護(hù)手術(shù)手臂免受過(guò)度活動(dòng)（ Video 1 ， Fig 8 ）。在術(shù)后立即階段，患者可能受益于冷療，以減少腫脹、改善疼痛控制并降低手術(shù)的炎癥反應(yīng)。 ⁶³ 肩胛下肌修復(fù)后，患者需遵循一個(gè)逐漸恢復(fù)活動(dòng)范圍的方案。盡管在術(shù)后早期鼓勵(lì)手、腕和肘關(guān)節(jié)的主動(dòng)活動(dòng)范圍，但在前 4 周內(nèi)應(yīng)限制肩關(guān)節(jié)的主動(dòng)活動(dòng)范圍。術(shù)后被動(dòng)活動(dòng)范圍可能減少僵硬和粘連，因此是可接受的。 然而，在我們機(jī)構(gòu)，我們建議患者在術(shù)后 4 至 6 周內(nèi)避免超過(guò) 30°的外旋（被動(dòng)或主動(dòng)），因?yàn)檫@會(huì)導(dǎo)致修復(fù)部位過(guò)度緊張。根據(jù)修復(fù)部位的張力情況，可在術(shù)后 5 至 6 周停止吊帶，并開(kāi)始輔助主動(dòng)和主動(dòng)活動(dòng)范圍練習(xí)。然后繼續(xù)康復(fù)訓(xùn)練，重點(diǎn)在于恢復(fù)肌肉耐力和活動(dòng)范圍。 ⁶² 最后，在患者恢復(fù)到之前活動(dòng)水平之前，會(huì)逐漸重新引入增強(qiáng)肌肉力量和力量的練習(xí)。 ⁶²

Fig 8.  圖 8。

Table 1.  表 1。

Pearls and Pitfalls of Subscapularis Repair
肩胛下肌修復(fù)的要點(diǎn)與陷阱

MRI, magnetic resonance imaging.
核磁共振成像，MRI。

Table 2.  表 2。

Selected Advantages and Disadvantages Related to Subscapularis Repair
與肩胛下肌修復(fù)相關(guān)的優(yōu)缺點(diǎn)