旋轉肌袖對於肩關節的活動及功能來說至關重要。然而，隨著年齡、反覆工作受力、或意外事故，旋轉肌袖撕裂並不罕見，特別是在年紀六十歲以後。關節鏡旋轉肌袖縫合手術在近二十年已經成為主要的治療方式，無論外排固定 (single row)、雙排固定 (double row)、或是內外排交叉固定 (suture bridge)等均有不錯的臨床結果。雖然固定效果不錯，但據統計仍有5%-84%再撕裂的機率，特別是依照Cofield分類下大或巨大撕裂的患者。另一方面，旋轉肌袖撕裂偶爾也伴隨肱二頭肌長肌腱在關節內段的病變。由於肱二頭肌長肌腱在肩關節角色仍不明確，對於肱二頭肌長肌腱的病變，在肱二頭肌長肌腱源頭端進行切除手術減少術後疼痛是目前治療的方法之一。
對於巨大(撕裂範圍大於5公分)、無法縫合的旋轉肌袖撕裂在過去進行部分縫合、或是使用軟組織嫁接的方式來處理，術後的效果不明確。近十年來，上關節囊重建伴隨旋轉肌袖部分縫合有穩定的術後結果。這樣的手術，無論在生物力學或是臨床結果研究上均優於過去的部分縫合、或是使用軟組織嫁接等方式。最早上關節囊重建的組織來自於自體闊筋膜張肌(tension fascia lata)。近年來，自體肱二頭肌長肌腱、異體闊筋膜張肌、或是異體去細胞皮膜層 (humeral acellular dermal patches)拿來作上關節囊重建組織也有不錯的生物力學或是臨床結果。然而，對於大或巨大可縫合旋轉肌袖撕裂雖然可以經由關節鏡進行旋轉肌袖完全縫合，但仍有很高的再撕裂機率。上關節囊重建併關節鏡旋轉肌袖縫合可能可以降低再撕裂機率，但文獻中這樣的做法討論甚少。在一篇高品質的報告裡，針對可縫合的旋轉肌袖撕裂進行自體闊筋膜張肌作上關節囊重建併旋轉肌袖縫合手術。在一年的追蹤，再撕裂率降低至0%。另一方面，自體肱二頭肌長肌腱作上關節囊重建相較於其他植體，有甚少的捐贈處的併發症、較簡單的手術技術、較少的手術時間、較低的感染率及較少的手術花費。而生物力學實驗也證實自體肱二頭肌長肌腱相較於自體闊筋膜張肌作上關節囊重建有著相同、甚至更好的力學表現。雖然自體闊筋膜張肌作上關節囊重建併旋轉肌袖縫合手術有著極佳的臨床結果，但使用自體肱二頭肌長肌腱上關節囊重建併旋轉肌袖縫合手術除了一篇手術技巧文章外，並無臨床結果的文章。另一方面，肱二頭肌長肌腱作上關節囊重建是使用lasso-loop縫合的方式進行固定。這樣的固定方法難度較高且需要專業的手術器械(penetrating grasper)。因此，這份研究進行兩部分探討：第一，手術方式的改良及簡化，特別是讓肱二頭肌長肌腱作上關節囊重建進行簡單且有效的固定；第二，藉由新改良的技術，針對大或巨大但可縫合旋轉肌袖撕裂病人進行最少兩年的臨床結果評估。
回溯研究40位有著大或巨大但可縫合旋轉肌袖撕裂病人，第一組自2017年2月到2018年6月共18個病人進行肱二頭肌長肌腱作上關節囊重建併關節鏡旋轉肌袖縫合手術；第二組自2015年1月到2017年1月共22個病人進行肱二頭肌長肌腱源頭端切除併關節鏡旋轉肌袖縫合手術。對於疼痛，術前、術後1、3、6、12、24個月使用VAS分數評估；對於功能、主動活動角度，術前、術後6、12、24個月使用ASES及UCLA分數評估。術後一年，用核磁共振評估縫合的旋轉肌袖及重建的上關節囊。兩組病人在各種病人特徵上均沒有差別，且兩組病人術後相較於術前，無論疼痛、功能、滿意度上較術前均有顯著的進步。第一組在早期疼痛緩解(術後第1、3個月)、前舉(術後第6個月)、外轉(術後第6個月)、內轉(術後第6、12、24個月)相較於第二組都有顯著的改善。旋轉肌袖再撕裂機率來說，第一組[16.7% (3/18)]顯著低於第二組[40.9% (9/22)]。肱二頭肌長肌腱作上關節囊重建存活率是94.4%(17/18)。徒手鬆筋造成醫源性肩盂骨折的罕見病例也在收案過程中發生，在進行關節鏡肩盂骨折固定及旋轉肌袖縫合手術後兩年，病人也對治療的結果感到滿意。
回顧文獻，這是第一篇使用肱二頭肌長肌腱作上關節囊重建併關節鏡旋轉肌袖縫合手術針對大或巨大但可縫合旋轉肌袖撕裂病人進行的臨床結果研究。相較於傳統的肱二頭肌長肌腱源頭端切除併關節鏡旋轉肌袖縫合手術，有早期復原、較少旋轉肌袖再撕裂機率及極高的上關節囊重建存活率。研究的結果對於未來面對高再撕裂的旋轉肌袖縫合手術提供其他治療選擇。

The rotator cuff is a vital organ to make shoulder motion and function. However, rotator cuff tear (RCT) is not an uncommon disease, especially for more than 60 years old. The single row, double row, or suture bridge under arthroscopic rotator cuff repair (ARCR) have become a mainstream treatment for RCT in the past 2 decades. However, the retear rates after ARCR vary from 5% to 84%, especially for the patient with large to massive RCT according to Cofield classification. On the other hand, the role of intraarticular part of the long head of the biceps tendon (LHBT) remains controversial. The tenotomy of the LHBT at its insertion is a reasonable treatment for the LHBT pathology combined with RCT.
The superior capsule reconstruction (SCR) combined partial rotator cuff repair became the new choice for irreparable RCT in recent 10 years. Whether biomechanical results or the clinical outcomes, this combination are better than only partial ARCR or ARCR with soft tissue interposition. Autogenous LHBT, tension fascia lata (TFL), allogenous TFL or humeral acellular dermal patches are used as SCR and the results are reliable. However, SCR combined with ARCR for reparable RCT is rarely discussed, even though these patients have a high retear rate after ARCR alone. The retear rate is excellent 0% after 1-year follow-up by using autogenous TFL as SCR combined ARCR for reparable large to massive RCT is reported by a high-quality paper. Unlike autogenous TFL as SCR, the advantages of LHBT as SCR are less donor-site morbidity, less demanding techniques, reducing operative time, lower infection rate, and less extra-cost. Several biomechanical results show the LHBT as SCR is equivalent and potentially stronger than TFL as SCR. Even so, LHBT as SCR for reparable RCT is only techniques notes without clinical outcomes after literature reviews. Therefore, the improvement and simplification of surgical techniques of the LHBT as SCR combined with ARCR for reparable RCT is the first objective, especially for the improvement of the fixation methods of LHBT. The clinical outcomes with a minimum of 2 years of follow-up under these surgical techniques is the second objective, especially for the patients with large to massive reparable RCTs. The better clinical outcomes and lower retear rate after LHBT as SCR combined with ARCR compared to ARCR alone are the hypothesis.
The forty patients with large to massive reparable RCTs were retrospectively evaluated between January 2015 and June 2018. There were eighteen patients who underwent ARCR and LHBT as SCR (group I) between February 2017 and June 2018, and there were twenty-two patients who underwent ARCR and tenotomy of LHBT performed at the insertion site (group II) between January 2015 and January 2017. The pain visual analog score (VAS) was assessed preoperatively and 1, 3, 6, 12, 24 months postoperatively. American Shoulder and Elbow Surgeons (ASES) scores, the University of California, Los Angeles (UCLA) shoulder rating scale, and active range of motion (AROM) were assessed before surgery and 6, 12, and 24 months after surgery. The integrity of the rotator cuff and SCR was evaluated using magnetic resonance images at 12 months postoperatively. After surgery, both groups had significantly improved in VAS, ASES, UCLA and AROM in the final follow-up. There were no significant between-group differences in the characteristics of the patients before surgery. For pain relief, Group I was the better improvement than Group II at 1 month (P < .001) and at 3 months (P <.01) after surgery. For the AROM, Group I (flexion, external rotation, internal rotation) demonstrated better improvement than group II at 6 months after surgery (all P < .05) and better internal rotation at 12 and 24 months after surgery (all P < .05). The SCR survival rate was 94.4% (17/18). The retear rate of repaired rotator cuffs for Groups I and II was 16.7% (3/18) and 40.9% (9/22), respectively, and the differences were significant (P < .046). On the other hand, a rare case of the iatrogenic glenoid fracture after manipulation was happened in the process of the case collections. This case felt satisfied after ARCR and arthroscopic fixation of the iatrogenic glenoid fracture in the 2 years of follow-up.
This is the first study of the clinical and images outcomes of ARCR combined with LHBT as SCR for large to massive reparable RCTs. The results may lead to a lower retear rate and earlier functional recovery than conventional ARCR with tenotomy of LHBT for large to massive reparable RCTs. For the patients with the higher retear rate of the reparable RCTs, these papers provide the other treatment options in the future.

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