旋轉袖肌斷裂與二頭肌肌腱病變的關聯性研究與旋轉袖肌斷裂術後復健時間點的統合分析

Association of Biceps Tendon Lesions with Rotator Cuff Tears and a Meta-analysis for Timing of Rehabilitation after Rotator Cuff Repair

張凱閔(Ke-Vin Chang)

指導教授 ： 簡國龍

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/博士(2015年)

https://doi.org/10.6342/NTU.2015.02146

摘要

背景與目的:
旋轉袖肌是維持肩膀穩定與活動重要的構造，而其斷裂會導致患者不等程度的疼痛與功能受損。二頭肌長頭肌腱，是常規肩膀超音波檢查中首先檢查的構造，不僅位置緊連旋轉袖肌，更與其有功能上的協同作用。目前對於旋轉袖肌斷裂與二頭肌長頭肌腱相關研究仍有限，以往研究多著重在需肩關節鏡介入的患者，跟臨床門診肩痛患者的嚴重度明顯有差異。同時針對旋轉袖肌斷裂術後的復健處方，何時開始被動式關節活動仍無共識。因此本篇論文將探討旋轉袖肌斷裂與二頭肌長頭肌腱的相關性，並且比較及早與延遲的被動式關節活動對接受關節鏡旋轉袖肌修補術後患者成效的影響。

方法:
我們分析了2011 至2012 年間接受肩膀超音波的患者影像。二頭肌肌腱旁積液，根據量測的厚度，分為無(小於1 mm)、輕微(1 到2 mm)、中等(2 到3 mm)與嚴重(>3 mm)。利用羅吉斯回歸分析二頭肌肌腱旁積液與旋轉袖肌斷裂的關係，並以年齡、性別、患側與臨床診斷之沾黏性關節炎等變數校正。至於旋轉袖肌斷裂與二頭肌長頭肌腱型態學的相關性，則是選取具脊上肌全層斷裂的患者，以及年齡與性別相配對的控制組。我們測量二頭肌長頭肌腱的寬度、厚度、扁平比、橫截面積與回音度比，並且利用線性回歸模式探討脊上肌全層斷裂與二頭肌長頭肌腱型態學間的相關性，以及使用接受者操作特徵曲線針對所得出的參數，進行旋轉袖肌全層斷裂的區辨。有關於接受關節鏡旋轉袖肌修補術患者術後的復健處方的選擇，我們使用統合分析的方式比較及早與延遲的被動式關節活動的成效。我們主要利用PubMed 與 Scopus 來篩選比較上述兩種復健處方的隨機分派實驗。肩關節功能的差異則轉化成效應值來比較，而改善關節僵硬的效應與肌腱修補失敗的風險，則利用標準化的關節活動度差異與再發性旋轉袖肌撕裂的勝算比來比較。

結果:
在907 位肩痛患者中，利用無二頭肌肌腱旁積液來當做控制組，脊上肌全層斷裂與不同層度的肌腱旁積液皆顯著相關，而肩胛下肌的斷裂則與中度到嚴重的積液量相關。嚴重的積液也與脊上肌關節面部分層斷裂相關(勝算比, 18.12, 95%信賴區間, 4.54-72.32)。在二頭肌型態學部分，脊上肌全層斷裂與二頭肌厚度增厚、截面積增大與扁平比降低相關。扁平比是區辨脊上肌全層斷裂的最佳指標，其接收者操作特徵曲線為0.81 (95%信賴區間為0.76–0.86)。至於比較及早與延遲的被動式關節活動，對於接受關節鏡旋轉袖肌修補術患者術後復健成效的統合分析，共收錄6篇隨機分派研究，共482位患者。雖然及早的關節活動較延遲的復健處方可改善較多關節活動度，但對於肩關節功能兩者間無差異存在。早期的關節活動有增加再發性肌腱斷裂的傾向，在移除兩篇僅收納小程度與中程度的肌腱斷裂的隨機研究變成有統計上顯著的效應(勝算比, 1.93, 95%信賴區間為1.04-3.60)。

結論:
本論文顯示二頭肌肌腱旁積液與各樣的肩關節病變有相關，且相關的程度隨肌腱旁積液量不同而有差異，同時超音波可偵測到脊上肌腱全層斷裂後，關節外二頭肌肌腱的型態變化，因此建議臨床醫師須對二頭肌肌腱旁積液去做定量以及分析二頭肌腱的形態學。至於有接受過關節鏡旋轉袖肌縫補術後的患者，需先評估再發性肌腱斷裂與肩膀術後僵硬的風險後，再選擇及早或延遲的關節活動復健策略。

關鍵字

肩膀 ； 旋轉袖肌肌腱 ； 二頭肌肌腱 ； 超音波 ； 關節鏡 ； 復健

並列摘要

Background and objectives:
Limited numbers of studies investigated the association between rotator cuff (RC) tears and the long head of biceps tendon (LHBT) pathology.There is no consensus about the best timing to initiate passive range of motion (PROM)exercise following RC repair. The dissertation aims to explore the relationships between RC tears and LHBT pathology and also to compare outcomes between early and delayed PROM exercise for patients receiving arthroscopic RC repair.

Methods:
We investigated reports of patients undergoing shoulder ultrasound examinations between January 2011 and January 2012. Biceps peritendinous effusion (BPE) was graded according to its measured thickness, as absent (<1 mm), mild (1–2 mm), moderate (2–3 mm), or severe (>3 mm). The associations between BPE and RC tears were examined using logistic regression. Regarding the morphological association between RC tears and LHBT morphology, cases with supraspinatus tendon full thickness tear (SSFT) and age-and- gender-matched controls were chosen. The width, thickness, flattening ratio, cross-sectional area, and echogenicity ratio of the LHBT were measured and analyzed by a linear regression model. The receiver operating characteristic curves of each parameter were constructed for SSFT discrimination. Regarding the rehabilitation protocol for patients following arthroscopic RC repair, we used a systematic review and meta-analysis to compare early and late PROM exercise.

Results:
In 907 shoulder pain patients, SSFT was significantly associated with the entire spectrum of BPE, while subscapularis tendon tear was significantly associated with moderate to severe BPE. Severe BPE was associated with articular-sided partial-thickness tear of the supraspinatus tendon. SSFT was associated with an increase in the thickness and cross-sectional area and a decrease in the flattening ratio of LHBT. The flattening ratio was the best discriminator for SSFT with an area under curve of 0.81 [95% confidence interval (CI), 0.76–0.86]. Regarding the meta-analysis, 6 RCTs were included, comprising 482 patients. Although the early ROM group demonstrated more ROM improvement than the delayed rehabilitation group, no difference in shoulder function was identified between both protocols. Early ROM exercise tended to cause a higher rate of recurrent tendon tear, and the effect became statistically significant (odds ratio, 1.93, 95% CI, 1.04-3.60) after excluding 2 trials that recruited only patients with small to medium-sized RC tears.

Conclusions:
The thesis indicated BPE was related to various shoulder abnormalities. SSFT was associated with the morphology changes of the extra-articular LHBT
examined using ultrasound. Regarding patients following arthroscopic rotator cuff repairs, a proper choice of either rehabilitation protocol should be established based on an assessment of risks between recurrent tears and postoperative shoulder stiffness.

並列關鍵字

Shoulder ； Rotator Cuff ； Biceps Tendon ； Arthroscopy ； Rehabilitation

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