Warner J P, Krushell R J, Masquelet A, Gerber C
Department of Orthopaedic Surgery, University of Bern, Switzerland.
J Bone Joint Surg Am. 1992 Jan;74(1):36-45.
Thirty-one shoulders in eighteen cadavera were dissected to allow study of the neurovascular anatomy of the rotator cuff and to help determine the limits of mobilization of the cuff for the repair of chronic massive retracted tears. The dissection demonstrated the diameter, length, and relationships of the suprascapular nerve and its branches and made clear the dangers of extensive mobilization and advancement of the supraspinatus and infraspinatus muscles. The suprascapular nerve ran an oblique course across the supraspinatus fossa, was relatively fixed on the floor of the fossa, and was tethered underneath the transverse scapular ligament. In twenty-six (84 per cent) of the thirty-one shoulders, there were no more than two motor branches to the supraspinatus muscle, and the first was always the larger of the two. In twenty-six (84 per cent) of the thirty-one shoulders, the first motor branch originated underneath the transverse scapular ligament or just distal to it. In one shoulder (3 per cent), the first motor branch passed over the ligament. The average distance from the origin of the long tendon of the biceps to the motor branches of the supraspinatus was three centimeters. In fifteen (48 per cent) of the thirty-one shoulders, the infraspinatus muscle had three or four motor branches of the same size. The average distance from the posterior rim of the glenoid to the motor branches of the infraspinatus muscle was two centimeters. The motor branches to the supraspinatus muscle were fewer, usually smaller, and significantly shorter than those to the infraspinatus muscle. The standard anterosuperior approach allowed only one centimeter of lateral advancement of either tendon and limited the ability of the surgeon to dissect safely beyond the neurovascular pedicle. The advancement technique of Debeyre et al., or a modification of that technique, permitted lateral advancement of each muscle of as much as three centimeters and was limited by tension in the motor branches of the suprascapular nerve. In some situations, the safe limit of advancement may be even less. We concluded that lateral advancement of the rotator cuff is limited anatomically and may place the neurovascular structures at risk.
对18具尸体的31个肩部进行了解剖，以研究肩袖的神经血管解剖结构，并帮助确定在修复慢性巨大回缩性撕裂时肩袖的活动限度。解剖显示了肩胛上神经及其分支的直径、长度和相互关系，并明确了冈上肌和冈下肌广泛活动和前移的风险。肩胛上神经斜行穿过冈上肌窝，相对固定于窝底，并在肩胛横韧带下方受束缚。在31个肩部中的26个（84%），冈上肌的运动分支不超过两个，且第一个分支总是两个中较大的。在31个肩部中的26个（84%），第一个运动分支起源于肩胛横韧带下方或其稍远侧。在1个肩部（3%），第一个运动分支越过了该韧带。肱二头肌长头起点至冈上肌运动分支的平均距离为3厘米。在31个肩部中的15个（48%），冈下肌有3或4个大小相同的运动分支。肩胛盂后缘至冈下肌运动分支的平均距离为2厘米。冈上肌的运动分支较少，通常较小，且明显短于冈下肌的运动分支。标准的前上方入路仅允许任一肌腱向外移位1厘米，并限制了外科医生在神经血管蒂之外进行安全解剖的能力。Debeyre等人的移位技术或该技术的改良方法允许每块肌肉向外移位多达3厘米，并受肩胛上神经运动分支张力的限制。在某些情况下，安全移位限度可能更小。我们得出结论，肩袖的向外移位在解剖学上是有限的，可能会使神经血管结构处于危险之中。
