【作者】 凌奕清；

【导师】 范顺武；

【作者基本信息】 浙江大学 ， 外科学（专业学位）， 2013， 博士

【摘要】 背景和目的目前MRI是诊断肩袖损伤的重要影像学检查手段,肩袖损伤的特殊物理检查被认为具有一定的诊断价值。研究比较MRI及特殊物理检查对诊断冈上肌撕裂的敏感度、特异性及准确性。普通X线平片是肩关节检查的首选方法,肩峰-肱骨头(A-H)间距被认为是诊断肩袖撕裂的一个指标。分析并比较A-H大小与肩袖撕裂的关系。MRI除能提供直接的肩袖撕裂影像学证据,还能提供一些间接的证据帮助诊断并预测肩袖撕裂的愈后。肩袖肌肉萎缩被认为对肩袖撕裂具有指导意义,其测量指标有冈上肌占有率及tangent征,研究该两种指标对预测肩袖撕裂诊断的价值。随访关节镜下肩袖修补术后患者恢复,寻找影响术后恢复的预测因素。材料和方法收集并分析贯序74例因肩关节疼痛住院检查治疗患者,其中术前诊断考虑肩袖损伤63例,非肩袖损伤11例,男性33人,女性41人,分别行特殊物理检查、X线、MRI检查。特殊物理检查Jobe征、落臂征及疼痛弧征等,X线测量肩肱距离A-H, MRI评估冈上肌撕裂、冈上肌占有率及Tangent征。最终行关节镜检查并治疗,明确诊断,分析比较MRI和特殊物理检查Jobe征、落臂征、疼痛弧征对冈上肌撕裂的诊断准确性。术后随访患者,用UCLA肩关节评分评估患者愈后。结果74例患者经肩关节镜检查诊断为肩袖撕裂46例,其中冈上肌撕裂45例(按撕裂大小分为≤3cm组,27例；3-5cm组,10例；>5cm组,8例)。Jobe征诊断冈上肌撕裂的敏感度为82.2%(37/45),特异性45.0%(9/20),准确率为70.8%,MRI诊断的敏感度为88.9%(40/45),特异性为44.8%(13/29),准确率为71.6%。疼痛弧征的敏感度为80%(36/45),特异性为30%(6/20),准确率为64.6%；落臂征敏感度为42.2%(19/45),特异性为80%(16/20),准确率为53.8%。Tangent征的敏感度为22.2%(10/45),特异性96.6%(1/29),阳性预测值为91.0%。Jobe征与MRI联合诊断对冈上肌撕裂的敏感度为100%(45/45),特异性10%(2/20),准确率72.3%。74例患者中,肩肱距离A-H≤5mm共2例,肩袖损伤占100%；A-H5-10mm共56例,肩袖损伤占67.8%；A-H>10mm共16例,肩袖损伤占37.5%,p=0.03,组间有显著性差异。以A-H≤10mm为诊断标准,它对肩袖撕裂诊断的敏感度为87.0%(40/46),特异性为35.7%(10/28),准确率为67.6%。45例冈上肌撕裂中,按肩袖撕裂大小分组,各组间A-H并无明显差异,p=0.414。MRI上测得冈上肌占有率平均90.3±21.2%,冈上肌撕裂组45例,平均占有率86.6±21.7%,非冈上肌撕裂组29例,平均占有率96.1±19.4%；P=0.06。冈上肌撕裂病人中,Tangent征阳性10例,平均撕裂大小5.15±1.49cm, Tangent征阴性35例,平均撕裂大小2.67±1.37cm,P<0.001,40例冈上肌肌腱撕裂行关节镜修补术患者术后随访UCLA评分平均28.63±3.74分,优良率70.0%(28/40)。撕裂大小>5cm组平均为24.63±4.03分,与其他两组有显著性差异,P<0.001。Tangent征阳性患者平均24.70±3.40分,愈后明显差于Tangent征阴性患者,P<0.001。撕裂行关节镜修补术患者愈后与冈上肌占有率及撕裂大小相关,而与年龄无关。结论对于冈上肌肌腱撕裂,MRI具有较高的敏感性。Jobe征是一种可靠的物理诊断方法,和MRI有相近的敏感度和特异性,Jobe征与MRI、肩关节镜检查诊断结果差异无统计学意义。Jobe征与MRJ联合诊断的敏感性高达100%。A-H在肩袖撕裂组较非肩袖撕裂组为短,冈上肌占有率在冈上肌撕裂组较非冈上肌撕裂组为小,但均无统计学差异。A-H≤10mm和Tangent征阳性是提示肩袖撕裂的两个重要参数。A-H与冈上肌撕裂大小无关,而冈上肌占有率与撕裂大小负相关。Tangent征阳性提示更为严重的冈上肌萎缩,并且与更大的冈上肌撕裂相关。肩袖修补术后功能评分与冈上肌撕裂大小及冈上肌占有率相关,而与年龄无更多还原

【Abstract】 Backgroud and ObjectiveMRI is the most common imaging test in rotator cuff tear diagnosis. Special physical tests are also useful in clinic diagnosis. The purpose of this study is to determine the clinical usefulness of the MRI and special physical tests for determining the presence of supraspinatus tendon tear; find out Acromio-Humeral (A-H) distance, tangent sign and occupation ratio as the diagnosis factor of rotator cuff tear; determine the relationship of age, size of tear, occupation ratio and functional outcomes in patients with supraspinatus tendon tear who underwent arthroscopic repaire.MethodsA review was performed in a group of consecutive74patients,63of which were diagnosed rotator cuff tear preoperation,33men and41women, with shoulder pain who underwent arthroscopy in our hospital. All patients had a series of special physical examinations included Jobe’s test, drop arm sign and pain arc sign. X-ray and MRI of the involved shoulder. Using X-ray we measured the A-H distance and using MRI,we determined supraspinatus tendon tear, the supraspinatus muscle occupation ratio and the tangent sign. The diagnostic results were confirmed by the arthroscopy. We compared the diagnostic values of MRI and the special physical tests for the evaluation of supraspinatus tendon tear. We assessed functional outcomes by the UCLA scoring systems at long-term follow-up.Results46patients in74were diagnosed with rotator cuff tear after arthroscopy, included45supraspinatus tendon tear (According to tear size, they were divided into three groups:group A≤3cm27patients; group B3-5cm10patients; group C>5cm8patients). For the supraspinatus tendon tear, the Jobe’s test had a sensitivity of82.2%(37/45), a specificity of45.0%(9/20) and a diagnostic accuracy of70.8%while the MRI had a sensitivity of88.9%(40/45), a specificity of44.8%(13/29) and a diagnostic accuracy of71.6%. The pain arc sign and drop arm sign had respectivesensitivities of80%(36/45) and42.2%(19/45), respective specificities of30%(6/20) and80%(16/20), and respectivediagnostic accuracies of64.6%and53.8%. The tangent sign had a sensitivity of22.2%(10/45), a specificity of96.6%(1/29) and a positive predictive value of91.0%. The MRI combined with the Jobe’s test had an excellent sensitivity of100%(45/45). a specificity of10.0%(2/20) and a diagnostic accuracy of72.3%.We measured all patients’A-H distance and divided them into3groups, A-H≤5mm, A-H5-10mm and A-H>10mm. There were only2patients in group A-H≤5mm, the prevalence rate of rotator cuff tear was100%(2/2); in group A-H5-10mm, the prevalence rate was67.8%(38/56) and in group A-H>10mm. the prevalence rate was37.5%(6/16). A-H≤10mm had a sensitivity of87.0%(40/46), a specificity of35.7%(10/28) and a diagnostic accuracy of67.6%The mean supraspinatus muscle occupation ratio of all patients was90.3±21.2%. The mean occupation ratio of the45supraspinatus tendon tear patients was 86.6±21.7%vs96.1±19.4%in patients of non-supraspinatus tendon tear(p=0.06). The10patients with tangent sign positive had a mean size of tear5.15±1.49cm and the rest35tangent sign negative patients had a mean size of tear2.67±1.37cm (P<0.001) among the45supraspinatus tendon tear patientsAll of the40patients who accepted arthroscopic rotator cuff repair were available for follow-up. The mean score was28.63±3.74. The group of tear size>5cm had the worst score in all three groups and the group of tangent sign positive was significant worse than the group of tangent sign negative (P<0.001). The outcomes of rotator cuff repair are related to the size of tear and the occupation ratio of supraspinatus but not increasing age.ConclusionsJobe’s test is a reliable modality as MRI in diagnosis of supraspinatus tendon tear. There is no statistically significant difference between Jobe’s Test and MRI, Jobe’s Test and arthroscopy in diagnosis of supraspinatus tendon tear. The MRI combined with the Jobe’s test had an excellent sensitivity of100%. A-H distance in rotator cuff tear group is shorter than those in non-rotator cuff tear group. A-H distance≤10mm and Tangent sign positive are good predictors of rotator cuff tear. But A-H distance isn’t correlated to tear size, while tangent sign positive suggests more severe supraspinatus muscle atrophy and associates with greater supraspinatus tendon tear. The UCLA scoring for post rotator cuff repair is related to the size of tear and the occupation ratio of supraspinatus but not increasing age.更多还原